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WAL-MART PHARMACY 10-2052
CH09194B MENDOCINO COMMUNITY HEALTH CLINIC, INC.
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Covered Entity Details
Entity Name
MENDOCINO COMMUNITY HEALTH CLINIC, INC.
Subdivision Name
LAKEVIEW HEALTH CENTER
Type
HRSA-Funded Health Center
340B ID
CH09194B
Entity Address
5335 Lakeshore Blvd
Lakeport, CA 95453-6123
Grant Number
H80CS00628
Participating Start Date
4/1/2011
Last Recertification Date
2/25/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2052
Pharmacy Address
1155 AIRPORT PARK BLVD.
UKIAH, CA 95482
Pharmacy Comments
Contract Details
Approval Date
10/24/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Rod Grainger, CEO
(707) 472-4667
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/24/2023
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