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ANZA VALLEY PHARMACY
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
ANZA VALLEY PHARMACY
Pharmacy Address
56555 HIGHWAY 371
PO BOX 390415
ANZA, CA 92539
Pharmacy Comments
Contract Details
Approval Date
4/1/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/3/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Bill Thomsen, CEO
(909) 864-1097 Ext: 4703
Contract Pharmacy Representative
Soji Akanwo, COO
(951) 763-7670
Signed By Date
4/1/2015
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