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UPSTATE FAMILY DRUGS LLC
FQHCLA360A Upstate Family Health Center, Inc.
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Covered Entity Details
Entity Name
Upstate Family Health Center, Inc.
Subdivision Name
Upstate Family Health Center, Inc. Kernan SBHC
Type
Health Center Program Look-Alike
340B ID
FQHCLA360A
Entity Address
929 York Street
Utica, NY 13502-3929
Grant Number
LALCS31538
Participating Start Date
4/1/2018
Last Recertification Date
1/28/2020
Entity Termination Date
7/1/2020
Pharmacy Details
Pharmacy Name
UPSTATE FAMILY DRUGS LLC
Pharmacy Address
1001 NOYES ST
UTICA, NY 13502-4400
Pharmacy Comments
Contract Details
Approval Date
7/11/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jaime Oot, Director of Administration
(315) 624-9470 Ext: 2260
Contract Pharmacy Representative
Upstate Family Drugs
Mallika Kopalle, Owner
(732) 678-8459
Signed By Date
7/11/2019
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