Contract Pharmacy Details

LONGS DRUG STORES CALIFORNIA, L.L.C.
FQHC638409 CONSOLIDATED TRIBAL HEALTH PROJECT

Covered Entity Details

Entity Name

CONSOLIDATED TRIBAL HEALTH PROJECT

Subdivision Name

Type

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

340B ID

FQHC638409

Entity Address

6991 N. STATE STREET
REDWOOD VALLEY, CA 95470

Grant Number

Participating Start Date

7/1/2017

Last Recertification Date

2/10/2025

Pharmacy Details

Pharmacy Name

LONGS DRUG STORES CALIFORNIA, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 03932
150 S MAIN ST
FORT BRAGG, CA 95437

Pharmacy Comments

Contract Details

Approval Date

10/6/2020

Contract Begin Date

1/1/2021

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

2/10/2025
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

MARY ANN GONZALEZ, ACTING DIRECTOR
(707) 485-5115 Ext: 5634

Contract Pharmacy Representative

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

Signed By Date

10/6/2020

340B Drug Pricing Program Database