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MEDFORD PHARMACY GROUP, LLC
CH100790 LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC
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Covered Entity Details
Entity Name
LA CLINICA DEL VALLE FAMILY HEALTH CARE CENTER INC
Subdivision Name
PHOENIX HEALTH CENTER--LA CLINICA
Type
HRSA-Funded Health Center
340B ID
CH100790
Entity Address
3617 S Pacific Hwy
Medford, OR 97501-8957
Grant Number
H80CS00759
Participating Start Date
1/1/1999
Last Recertification Date
2/12/2025
Pharmacy Details
Pharmacy Name
MEDFORD PHARMACY GROUP, LLC
Pharmacy Address
DBA: WEST MAIN PHARMACY
2355 W MAIN ST
MEDFORD, OR 97501
Pharmacy Comments
Contract Details
Approval Date
1/14/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Traci Fossen, Chief Quality Officer
(541) 512-3912
Contract Pharmacy Representative
Peninsula Pharmacies Inc.
JEFF HARRELL, PRESIDENT
(360) 642-3200
Signed By Date
1/14/2020
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