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CHINO VALLEY PHARMACY
RWII86305 Northland Cares
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Covered Entity Details
Entity Name
Northland Cares
Subdivision Name
Northland Cares
Type
Ryan White Part B
340B ID
RWII86305
Entity Address
3188 N Windsong Drive
Suite A
Prescott Valley, AZ 86314
Grant Number
X07HA00080
Participating Start Date
7/1/2013
Last Recertification Date
2/27/2025
Pharmacy Details
Pharmacy Name
CHINO VALLEY PHARMACY
Pharmacy Address
1932 N STATE ROUTE 89
CHINO VALLEY, AZ 86323
Pharmacy Comments
Contract Details
Approval Date
10/14/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Johnny Martinez, Executive Director
(928) 776-4612
Contract Pharmacy Representative
Chino Valley Pharmacy
Jason Dykstra, Owner
(928) 515-0046
Signed By Date
10/14/2024
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