Contract Pharmacy Details

KELLY'S DRUG STORE
FQHC638480 MACT Health Board, Inc.

Covered Entity Details

Entity Name

MACT Health Board, Inc.

Subdivision Name

MACT Medical, Sonora

Type

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

340B ID

FQHC638480

Entity Address

13975 MONO WAY
SUITE G,H, I, J
SONORA, CA 95370

Grant Number

Participating Start Date

1/1/2003

Last Recertification Date

2/18/2025

Pharmacy Details

Pharmacy Name

KELLY'S DRUG STORE

Pharmacy Address

64 E. SAINT CHARLES STREET
SAN ANDREAS, CA 95249-0606

Pharmacy Comments

Contract Details

Approval Date

1/14/2016

Contract Begin Date

4/1/2016

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

John Shawver Alexander, Executive Director
(209) 754-6258

Contract Pharmacy Representative

John Nguyen, Owner
(209) 754-3595

Signed By Date

1/14/2016

340B Drug Pricing Program Database