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LONGS DRUG STORES CALIFORNIA, L.L.C.
FQHC638549 mathiesen memorial Health Clinic
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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 # 09539
41 N MAIN ST
ANGELS CAMP, CA 95222
Pharmacy Comments
Contract Details
Approval Date
10/2/2020
Contract Begin Date
1/1/2021
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
10/2/2020
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