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COULEE OWL PHARMACY
CAH501308-00 Douglas, Grant, Lincoln, Okanogan Counties Public Hospital District #6
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Covered Entity Details
Entity Name
Douglas, Grant, Lincoln, Okanogan Counties Public Hospital District #6
Subdivision Name
Coulee Medical Center
Type
Critical Access Hospital
340B ID
CAH501308-00
Entity Address
411 Fortuyn Road
Grand Coulee, WA 99133
Medicare Provider Number
501308
Participating Start Date
10/1/2013
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
COULEE OWL PHARMACY
Pharmacy Address
411 FORTUYN RD
GRAND COULEE, WA 99133
Pharmacy Comments
Contract Details
Approval Date
4/10/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ramona Hicks, Chief Executive Officer
(509) 633-6333
Contract Pharmacy Representative
Coulee Owl Pharmacy
Amanda Michelle Goyke, Pharmacist
(509) 633-6425
Signed By Date
4/10/2018
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