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WAL-MART PHARMACY 10-0829
CH06392B LA FAMILIA MEDICAL CENTER INC
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Covered Entity Details
Entity Name
LA FAMILIA MEDICAL CENTER INC
Subdivision Name
LA FAMILIA - SOUTHSIDE CLINIC
Type
HRSA-Funded Health Center
340B ID
CH06392B
Entity Address
2145 Caja Del Oro Grant Rd
Santa Fe, NM 87507-3279
Grant Number
H80CS00606
Participating Start Date
4/1/2004
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0829
Pharmacy Address
3251 CERRILLOS ROAD
SANTA FE, NM 87507
Pharmacy Comments
Contract Details
Approval Date
10/20/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brandon Vanessa Van Pelt, Interim CEO
(505) 982-4425 Ext: 1067
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/20/2023
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