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CENTRAL DRUG INC
CH100790 LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC
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Covered Entity Details
Entity Name
LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC
Subdivision Name
PHOENIX HEALTH CENTER--LA CLINICA
Type
HRSA-Funded Health Center
340B ID
CH100790
Entity Address
3617 S Pacific Hwy
Medford, OR 97501-8957
Grant Number
H80CS00759
Participating Start Date
1/1/1999
Last Recertification Date
2/12/2025
Pharmacy Details
Pharmacy Name
CENTRAL DRUG INC
Pharmacy Address
DBA BLACK OAK PHARMACY
2924 SISKIYOU BLVD STE 102
MEDFORD, OR 97504
Pharmacy Comments
Contract Details
Approval Date
10/11/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Traci Fossen, Chief Quality Officer
(541) 512-3912
Contract Pharmacy Representative
Black Oak Pharmacy
Timothy L Lichlyter, President
(541) 773-5356
Signed By Date
10/11/2018
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