Contract Pharmacy Details

EXPRESS PHARMACY
FQ114A MISSION CITY COMMUNITY NETWORK INC

Covered Entity Details

Entity Name

MISSION CITY COMMUNITY NETWORK INC

Subdivision Name

Mission City Community Network - Hollywood

Type

Health Center Program Look-Alike

340B ID

FQ114A

Entity Address

4842 Hollywood Blvd
Los Angeles, CA 90027

Grant Number

LALCS00029

Participating Start Date

7/1/2012

Last Recertification Date

2/17/2017

Entity Termination Date

4/1/2017

Pharmacy Details

Pharmacy Name

EXPRESS PHARMACY

Pharmacy Address

EXPRESS PHARMACY
752 E ARROW HWY
POMONA, CA 91767

Pharmacy Comments

Contract Details

Approval Date

10/13/2014

Contract Begin Date

1/1/2015

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2017

Contacts

Covered Entity Signing Official

Nik Gupta, CEO
(818) 895-3100

Contract Pharmacy Representative

JACK VASOYA, PHARMACIST
(909) 398-1289

Signed By Date

10/13/2014