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K MART PHARMACY #3682
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
K MART PHARMACY #3682
Pharmacy Address
1900 BATAAN MEMORIAL E
LAS CRUCES, NM 88011-6011
Pharmacy Comments
Contract Details
Approval Date
4/13/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/1/2017
Pharmacy closed
Contacts
Covered Entity Signing Official
Suzan Martinez de Gonzales, CEO
(575) 526-1105
Contract Pharmacy Representative
Kmart
Jennifer Speares, Director Administration/Compliance
(904) 783-5183
Signed By Date
4/13/2017
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