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THRIFTY PAYLESS, INC.
FQHC638558 Coyote Valley Band of Pomo Indians
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Covered Entity Details
Entity Name
Coyote Valley Band of Pomo Indians
Subdivision Name
Tribal Health and Human Services
Type
Tribal Contract/Compact with IHS (P.L. 93-638)
340B ID
FQHC638558
Entity Address
7601 North State Street
Redwood Valley, CA 95470-9492
Grant Number
Participating Start Date
1/1/2020
Last Recertification Date
Entity Termination Date
4/1/2020
Pharmacy Details
Pharmacy Name
THRIFTY PAYLESS, INC.
Pharmacy Address
RITE AID #6033
680 SOUTH STATE STREET
UKIAH, CA 95482
Pharmacy Comments
Contract Details
Approval Date
10/18/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Bernadette Mora, Tribal Administrator
(707) 485-8723
Contract Pharmacy Representative
Rite Aid
Chau Nguyen, Pharmacy Administrator
(707) 462-6850
Signed By Date
10/18/2019
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