Contract Pharmacy Details

RALEY'S PHARMACY #213
FQHCLA106 SIERRA FAMILY MEDICAL CLINIC, INC.

Covered Entity Details

Entity Name

SIERRA FAMILY MEDICAL CLINIC, INC.

Subdivision Name

Type

Health Center Program Look-Alike

340B ID

FQHCLA106

Entity Address

15301 TYLER FOOTE ROAD
NEVADA CITY, CA 95959

Grant Number

LALCS00058

Participating Start Date

4/1/2002

Last Recertification Date

2/2/2015

Entity Termination Date

4/1/2016

Pharmacy Details

Pharmacy Name

RALEY'S PHARMACY #213

Pharmacy Address

692 FREEMAN LANE
GRASS VALLEY, CA 95949

Pharmacy Comments

Contract Details

Approval Date

10/25/2010

Contract Begin Date

10/25/2010

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2016
Covered Entity Terminated

Contacts

Covered Entity Signing Official

RICHARD MANTLE, CFO
(530) 292-3478 Ext: 204

Contract Pharmacy Representative

Raley's
Flint Pendergraft, Vice President, Pharmacy & Healthy Lifestyle Initiatives
(916) 373-6146

Signed By Date

10/1/2010

340B Drug Pricing Program Database