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LONGS DRUG STORES CALIFORNIA, L.L.C.
FQHC638490 MACT Health Board, Inc.
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Covered Entity Details
Entity Name
MACT Health Board, Inc.
Subdivision Name
MACT Medical, San Andreas
Type
Tribal Contract/Compact with IHS (P.L. 93-638)
340B ID
FQHC638490
Entity Address
1113 Highway 49
SAN ANDREAS, CA 95249
Grant Number
Participating Start Date
7/1/2009
Last Recertification Date
2/18/2025
Pharmacy Details
Pharmacy Name
LONGS DRUG STORES CALIFORNIA, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 09390
200 E HIGHWAY 12 STE D
VALLEY SPRINGS, CA 95252
Pharmacy Comments
Contract Details
Approval Date
10/10/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
John Shawver Alexander, Executive Director
(209) 754-6258
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
10/10/2018
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