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NORTH LAKE MEDICAL PHARMACY #2
FQHC638009 LAKE COUNTY TRIBAL HEALTH CONSORTIUM, INC
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Covered Entity Details
Entity Name
LAKE COUNTY TRIBAL HEALTH CONSORTIUM, INC
Subdivision Name
Type
Tribal Contract/Compact with IHS (P.L. 93-638)
340B ID
FQHC638009
Entity Address
925 BEVINS COURT
LAKEPORT, CA 95453
Grant Number
Participating Start Date
1/1/1995
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
NORTH LAKE MEDICAL PHARMACY #2
Pharmacy Address
347 LAKEPORT BOULEVARD
LAKEPORT, CA 95453-5412
Pharmacy Comments
1/11/10 ADDR UPDATE (WAS 355 LAKEPORT BLVD)
Contract Details
Approval Date
1/1/2007
Contract Begin Date
1/1/2007
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Signed By Date
11/28/2006
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