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ROUTE 66 PHARMACY INC.
FQHCLA425A SUNRISE CLINICS
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Covered Entity Details
Entity Name
SUNRISE CLINICS
Subdivision Name
Santa Rosa High School School Based Clinic
Type
Health Center Program Look-Alike
340B ID
FQHCLA425A
Entity Address
717 S 3rd Street, Lion Care Office FL 1
Santa Rosa, NM 88435-2411
Grant Number
LALCS40211
Participating Start Date
7/1/2021
Last Recertification Date
2/11/2025
Pharmacy Details
Pharmacy Name
ROUTE 66 PHARMACY INC.
Pharmacy Address
117 CAMINO DE VIDA
SUITE 200
SANTA ROSA, NM 88435
Pharmacy Comments
Contract Details
Approval Date
4/15/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Randal Brown, CEO
(575) 472-4311
Contract Pharmacy Representative
Guadalupe County Hospital
Christina Campos, Administrator
(575) 472-5666
Signed By Date
4/15/2021
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