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WAL-MART PHARMACY 10-5315
FQHC638009 LAKE COUNTY TRIBAL HEALTH CONSORTIUM, INC
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Covered Entity Details
Entity Name
LAKE COUNTY TRIBAL HEALTH CONSORTIUM, INC
Subdivision Name
Type
Tribal Contract/Compact with IHS (P.L. 93-638)
340B ID
FQHC638009
Entity Address
925 BEVINS COURT
LAKEPORT, CA 95453
Grant Number
Participating Start Date
1/1/1995
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
7/11/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/13/2018
Agreement registered in error
Contacts
Covered Entity Signing Official
Emmanuel Y Yennyemb, Chief Operations Officer
(707) 263-8382 Ext: 1202
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
7/11/2018
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