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LAKE PHARMACY
CH09194C MENDOCINO COMMUNITY HEALTH CLINIC, INC.
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Covered Entity Details
Entity Name
MENDOCINO COMMUNITY HEALTH CLINIC, INC.
Subdivision Name
Dora Street Health Center, Suite B1
Type
HRSA-Funded Health Center
340B ID
CH09194C
Entity Address
1165 S Dora St Ste B1
Ukiah, CA 95482-6353
Grant Number
H80CS00628
Participating Start Date
7/1/2018
Last Recertification Date
2/25/2025
Pharmacy Details
Pharmacy Name
LAKE PHARMACY
Pharmacy Address
15230 LAKESHORE DR
CLEARLAKE, CA 95422
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
Lake Pharmacy
Tim Nguyen, Owner
(707) 994-3141
Signed By Date
10/24/2023
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