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WALGREEN CO.
FQHC638015 RIVERSIDE - SAN BERNARDINO COUNTY INDIAN HEALTH INC
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Covered Entity Details
Entity Name
RIVERSIDE - SAN BERNARDINO COUNTY INDIAN HEALTH INC
Subdivision Name
Morongo Indian Health Clinic
Type
Tribal Contract/Compact with IHS (P.L. 93-638)
340B ID
FQHC638015
Entity Address
11555 1/2 POTRERO RD
Banning, CA 92220
Grant Number
Participating Start Date
1/1/1995
Last Recertification Date
2/23/2025
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS #10172
1181 N STATE ST
SAN JACINTO, CA 92583
Pharmacy Comments
Contract Details
Approval Date
1/30/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/24/2015
Pharmacy closed
Contacts
Covered Entity Signing Official
Jess Montoya, CEO
(951) 849-4761
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/30/2014
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