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WHITE MOUNTAIN PHARMACY
CH092890 NORTH COUNTRY HEALTHCARE, INC.
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Covered Entity Details
Entity Name
NORTH COUNTRY HEALTHCARE, INC.
Subdivision Name
NORTH COUNTRY - FLAGSTAFF CLINIC
Type
HRSA-Funded Health Center
340B ID
CH092890
Entity Address
2920 N 4th St
Flagstaff, AZ 86004-1816
Grant Number
H80CS00651
Participating Start Date
7/1/1998
Last Recertification Date
2/18/2025
Pharmacy Details
Pharmacy Name
WHITE MOUNTAIN PHARMACY
Pharmacy Address
N & R BRYCE ENTERPRISES LLC
4461 S WHITE MOUNTAIN RD STE E1
SHOW LOW, AZ 85901-7782
Pharmacy Comments
Contract Details
Approval Date
7/18/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
ANNE NEWLAND, CEO
(928) 522-9564
Contract Pharmacy Representative
White Mountain Pharmacy
Nickalaus Bryce, Owner
(928) 243-0566
Signed By Date
7/18/2019
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