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TED'S VILLAGE PHARMACY INC
CH091140 SAN MATEO, COUNTY OF
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Covered Entity Details
Entity Name
SAN MATEO, COUNTY OF
Subdivision Name
39th Outpatient Clinics
Type
HRSA-Funded Health Center
340B ID
CH091140
Entity Address
222 W 39th Ave
San Mateo, CA 94403-4364
Grant Number
H80CS00051
Participating Start Date
10/1/2001
Last Recertification Date
3/5/2025
Pharmacy Details
Pharmacy Name
TED'S VILLAGE PHARMACY INC
Pharmacy Address
29 W 25TH AVE
SAN MATEO, CA 94403-2236
Pharmacy Comments
Contract Details
Approval Date
5/7/2012
Contract Begin Date
5/7/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
SUSAN EHRLICH, CEO
(650) 573-2041
Contract Pharmacy Representative
Nguyen Pham, Owner
(650) 349-1373
Signed By Date
3/23/2012
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