Contract Pharmacy Details

LONGS DRUG STORES CALIFORNIA, L.L.C.
FQHC638549 mathiesen memorial Health Clinic

Covered Entity Details

Entity Name

mathiesen memorial Health Clinic

Subdivision Name

Type

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

340B ID

FQHC638549

Entity Address

18144 Seco Street
Jamestown, CA 95327

Grant Number

Participating Start Date

4/1/2018

Last Recertification Date

2/28/2025

Pharmacy Details

Pharmacy Name

LONGS DRUG STORES CALIFORNIA, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 09390
200 E HIGHWAY 12 STE D
VALLEY SPRINGS, CA 95252

Pharmacy Comments

Contract Details

Approval Date

4/9/2020

Contract Begin Date

7/1/2020

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

John Richard Vass, CEO
(209) 984-4827 Ext: 2099844827

Contract Pharmacy Representative

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

4/9/2020

340B Drug Pricing Program Database