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WELLBORN PHARMACY, INC.
FQHCLA425E SUNRISE CLINICS
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Covered Entity Details
Entity Name
SUNRISE CLINICS
Subdivision Name
Sunrise Clinics - Las Vegas
Type
Health Center Program Look-Alike
340B ID
FQHCLA425E
Entity Address
2020 7th St
Las Vegas, NM 87701-4958
Grant Number
LALCS40211
Participating Start Date
7/1/2021
Last Recertification Date
2/11/2025
Pharmacy Details
Pharmacy Name
WELLBORN PHARMACY, INC.
Pharmacy Address
DBA MESA WINDS HEALTHMART PHARMACY
1923 S 1ST ST
TUCUMCARI, NM 88401
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
Wellborn Pharmacy
Brian K. Wilson, President
(575) 461-2784
Signed By Date
4/15/2021
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