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WAL-MART PHARMACY 10-1815
FQHCLA311 Greater Fresno Health Organization
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Covered Entity Details
Entity Name
Greater Fresno Health Organization
Subdivision Name
Kings Winery Medical Clinic
Type
Health Center Program Look-Alike
340B ID
FQHCLA311
Entity Address
4929 E Cesar Chavez Blvd
Fresno, CA 93727-3812
Grant Number
LALCS00041
Participating Start Date
10/1/2018
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1815
Pharmacy Address
4080 W SHAW AVE
FRESNO, CA 93722
Pharmacy Comments
Contract Details
Approval Date
7/10/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
BLA MOUANOUTOUA, CEO
(559) 255-6476 Ext: 4290
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
7/10/2023
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