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WAL-MART PHARMACY 10-4601
CH06301C LA CLINICA DE FAMILIA, INC.
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Covered Entity Details
Entity Name
LA CLINICA DE FAMILIA, INC.
Subdivision Name
SAN MIGUEL MEDICAL & DENTAL CLINIC
Type
HRSA-Funded Health Center
340B ID
CH06301C
Entity Address
18420 S. Highway 28
SAN MIGUEL, NM 88058
Grant Number
H80CS00316
Participating Start Date
12/1/1992
Last Recertification Date
2/17/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-4601
Pharmacy Address
3331 RINCONADA BLVD
LAS CRUCES, NM 88011
Pharmacy Comments
Contract Details
Approval Date
1/19/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Suzan Martinez de Gonzales, CEO
(575) 526-1105
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
1/19/2017
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