Contract Pharmacy Details

ABC PHARMACY
FQHCLA397A Health Service Alliance

Covered Entity Details

Entity Name

Health Service Alliance

Subdivision Name

Montclair Community Health Center

Type

Health Center Program Look-Alike

340B ID

FQHCLA397A

Entity Address

5050 San Bernardino St
Montclair, CA 91763-2326

Grant Number

LALCS33333

Participating Start Date

10/1/2019

Last Recertification Date

2/11/2025

Pharmacy Details

Pharmacy Name

ABC PHARMACY

Pharmacy Address

954 W FOOTHILL BLVD STE 6D
UPLAND, CA 91786-3782

Pharmacy Comments

Contract Details

Approval Date

10/14/2020

Contract Begin Date

1/1/2021

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Terry Chase, Chief Executive Officer
(909) 465-7193

Contract Pharmacy Representative

ABC Pharmacy
Edward Deng, VP
(909) 946-5512

Signed By Date

10/14/2020