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WAL-MART PHARMACY 10-1789
FQHCLA328 SAN JOAQUIN, COUNTY OF
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Covered Entity Details
Entity Name
SAN JOAQUIN, COUNTY OF
Subdivision Name
Primary Medicine Clinic
Type
Health Center Program Look-Alike
340B ID
FQHCLA328
Entity Address
500 W. Hospital Rd
Suite C
French Camp, CA 95231-9693
Grant Number
LALCS00158
Participating Start Date
10/1/2014
Last Recertification Date
2/11/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1789
Pharmacy Address
1601 S. LOWER SACRAMENTO RD.
LODI, CA 95242
Pharmacy Comments
Contract Details
Approval Date
4/14/2020
Contract Begin Date
6/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/26/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Farhan Fadoo, Chief Executive Officer
(209) 953-3700
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/14/2020
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