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WAL-MART PHARMACY 10-1324
CH090090 MARIPOSA COMMUNITY HEALTH CENTER, INC.
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Covered Entity Details
Entity Name
MARIPOSA COMMUNITY HEALTH CENTER, INC.
Subdivision Name
MARIPOSA COMMUNITY HEALTH CENTER
Type
HRSA-Funded Health Center
340B ID
CH090090
Entity Address
1852 N Mastick Way
Nogales, AZ 85621-1063
Grant Number
H80CS00752
Participating Start Date
12/1/1992
Last Recertification Date
2/11/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1324
Pharmacy Address
100 WEST WHITE PARK DR
NOGALES, AZ 85621
Pharmacy Comments
Contract Details
Approval Date
4/18/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ed Sicurello, CEO
(520) 761-2128
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
4/18/2017
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