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CYSTIC FIBROSIS SERVICES, LLC
STD875071 La Familia Medical Center
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Covered Entity Details
Entity Name
La Familia Medical Center
Subdivision Name
Southside clinic
Type
Sexually Transmitted Diseases
340B ID
STD875071
Entity Address
2145 Caja del Oro Grant Road
Santa Fe, NM 87507
Grant Number
1 NH25PS005180-01-00
Participating Start Date
4/1/2014
Last Recertification Date
5/14/2021
Entity Termination Date
7/1/2022
Pharmacy Details
Pharmacy Name
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
1/17/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jay Jolly, CEO
(505) 955-0310
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/17/2021
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