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SHALOM COMPOUNDING PHARMACY
FQ114A MISSION CITY COMMUNITY NETWORK INC
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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
SHALOM COMPOUNDING PHARMACY
Pharmacy Address
18000 VENTURA BLVD STE 2
ENCINO, CA 91316-9131
Pharmacy Comments
Contract Details
Approval Date
7/15/2016
Contract Begin Date
10/1/2016
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
Imanoel Pharmacy, DBA Sunshine Pharmacy
Eli Seleh, Pharmacist
(310) 666-0514
Signed By Date
7/15/2016
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