Contract Pharmacy Details

WAL-MART PHARMACY 10-1910
FQHC638024 UNITED INDIAN HEALTH SERVICES

Covered Entity Details

Entity Name

UNITED INDIAN HEALTH SERVICES

Subdivision Name

POTAWAT CLINIC

Type

Tribal Contract/Compact with IHS (P.L. 93-638)

340B ID

FQHC638024

Entity Address

1600 WEEOT WAY
ARCATA, CA 95521

Grant Number

Participating Start Date

1/1/1995

Last Recertification Date

3/3/2025

Pharmacy Details

Pharmacy Name

WAL-MART PHARMACY 10-1910

Pharmacy Address

900 EAST WASHINGTON BLVD
CRESCENT CITY, CA 95531

Pharmacy Comments

Contract Details

Approval Date

7/2/2014

Contract Begin Date

10/1/2014

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/31/2018
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Richard Baland, CFO
(707) 825-4065

Contract Pharmacy Representative

Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374

Signed By Date

7/2/2014

340B Drug Pricing Program Database