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CHINO VALLEY PHARMACY
STD86326 Northland Cares
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Covered Entity Details
Entity Name
Northland Cares
Subdivision Name
Cottonwood
Type
Sexually Transmitted Diseases
340B ID
STD86326
Entity Address
203 S. Candy Lane, Suite 3AB
Cottonwood, AZ 86326
Grant Number
6 NU62PS924550-05-06
Participating Start Date
4/1/2021
Last Recertification Date
5/15/2024
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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