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KELLY'S DRUG STORE
FQHC638490 MACT Health Board, Inc.
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Covered Entity Details
Entity Name
MACT Health Board, Inc.
Subdivision Name
MACT Medical, San Andreas
Type
Tribal Contract/Compact with IHS (P.L. 93-638)
340B ID
FQHC638490
Entity Address
1113 Highway 49
SAN ANDREAS, CA 95249
Grant Number
Participating Start Date
7/1/2009
Last Recertification Date
2/18/2025
Pharmacy Details
Pharmacy Name
KELLY'S DRUG STORE
Pharmacy Address
64 E. SAINT CHARLES STREET
SAN ANDREAS, CA 95249-0606
Pharmacy Comments
Contract Details
Approval Date
1/8/2010
Contract Begin Date
1/8/2010
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/29/2018
Pharmacy closed
Contacts
Covered Entity Signing Official
RICHARD CHOFFEY, EXECUTIVE DIRECTOR
(209) 754-6262
Contract Pharmacy Representative
JOHN NGUYEN, OWNER
(209) 754-3595
Signed By Date
12/18/2009
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