Contract Pharmacy Details

BLESSING PHARMACY
FQHC638541 Blackfeet Tribe

Covered Entity Details

Entity Name

Blackfeet Tribe

Subdivision Name

Southern Piegan Diabetes Progran

Type

Tribal Contract/Compact with IHS (P.L. 93-638)

340B ID

FQHC638541

Entity Address

503 Popimi Street
Browning, MT 59417-0850

Grant Number

Participating Start Date

4/1/2019

Last Recertification Date

Entity Termination Date

4/1/2020

Pharmacy Details

Pharmacy Name

BLESSING PHARMACY

Pharmacy Address

250 HOSPITAL CIR
WESTMINSTER, CA 92683-3953

Pharmacy Comments

Contract Details

Approval Date

2/6/2019

Contract Begin Date

4/1/2019

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2020
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Roberta Wagner, Administrator
(406) 338-7912

Contract Pharmacy Representative

Blessing Pharmacy
Anh Dao, Pharmacist in charge
(714) 373-0123

Signed By Date

1/15/2019