Contract Pharmacy Details

FALLBROOK PHARMACY
HV090720 NORTH COUNTY HEALTH SERVICES

Covered Entity Details

Entity Name

NORTH COUNTY HEALTH SERVICES

Subdivision Name

Type

Ryan White Part C

340B ID

HV090720

Entity Address

150 VALPREDA RD
SAN MARCOS, CA 92069

Grant Number

H76HA00168

Participating Start Date

12/1/1992

Last Recertification Date

3/9/2015

Entity Termination Date

10/1/2015

Pharmacy Details

Pharmacy Name

FALLBROOK PHARMACY

Pharmacy Address

343 E. ALVARADO ST.
FALLBROOK, CA 92028

Pharmacy Comments

Contract Details

Approval Date

8/23/2012

Contract Begin Date

8/23/2012

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

8/18/2015
Pharmacy closed

Contacts

Covered Entity Signing Official

Phil Lenowsky, CFO
(760) 736-6760

Contract Pharmacy Representative

Jan Balthasar, CEO
(949) 215-5522

Signed By Date

7/19/2012