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WAL-MART PHARMACY 10-3796
FQHCLA397A Health Service Alliance
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Covered Entity Details
Entity Name
Health Service Alliance
Subdivision Name
Montclair Community Health Center
Type
Health Center Program Look-Alike
340B ID
FQHCLA397A
Entity Address
5050 San Bernardino St
Montclair, CA 91763-2326
Grant Number
LALCS33333
Participating Start Date
10/1/2019
Last Recertification Date
2/11/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3796
Pharmacy Address
1333 NORTH MOUNTAIN AVENUE
ONTARIO, CA 91762-1105
Pharmacy Comments
Contract Details
Approval Date
4/15/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jeff Cox, Chief Executive Officer
(909) 784-6117
Contract Pharmacy Representative
Health Service Alliance
Jeff Cox, Chief Executive Officer
(909) 784-6117
Signed By Date
4/15/2025
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