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IMPERIAL PHARMACY
CH092500 IMPERIAL BEACH COMMUNITY CLINIC
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Covered Entity Details
Entity Name
IMPERIAL BEACH COMMUNITY CLINIC
Subdivision Name
IMPERIAL BEACH HEALTH CENTER
Type
HRSA-Funded Health Center
340B ID
CH092500
Entity Address
949 Palm Ave
Imperial Beach, CA 91932-1503
Grant Number
H80CS06648
Participating Start Date
4/1/1996
Last Recertification Date
2/26/2025
Pharmacy Details
Pharmacy Name
IMPERIAL PHARMACY
Pharmacy Address
1530 PALM AVE
SAN DIEGO, CA 92154
Pharmacy Comments
Contract Details
Approval Date
1/18/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Clinton Carroll Wiese, CFO
(619) 429-3733 Ext: 403
Contract Pharmacy Representative
Imperial Pharmacy
Prashant Koyani, Pharmacist
(909) 545-7587
Signed By Date
1/18/2022
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