Contract Pharmacy Details

FALLBROOK PHARMACY
FP9205411 NORTH COUNTY HEALTH SERVICES

Covered Entity Details

Entity Name

NORTH COUNTY HEALTH SERVICES

Subdivision Name

MISSION MESA PEDIATRICS

Type

Family Planning (Title X only)

340B ID

FP9205411

Entity Address

2210 MESA DR
SUITE 12
OCEANSIDE, CA 92054

Grant Number

FPHPA096061

Participating Start Date

4/1/2003

Last Recertification Date

5/21/2015

Entity Termination Date

10/1/2015

Pharmacy Details

Pharmacy Name

FALLBROOK PHARMACY

Pharmacy Address

343 E. ALVARADO ST.
FALLBROOK, CA 92028

Pharmacy Comments

Contract Details

Approval Date

8/23/2012

Contract Begin Date

8/23/2012

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/13/2015
Pharmacy closed

Contacts

Covered Entity Signing Official

Phil Lenowsky, CFO
(760) 736-6760

Contract Pharmacy Representative

Jan Balthasar, CEO
(949) 215-5522

Signed By Date

7/19/2012