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JEFFERSON PHARMACY
CHC24113-00 Elica Health Centers
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Covered Entity Details
Entity Name
Elica Health Centers
Subdivision Name
Elica Health Centers
Type
HRSA-Funded Health Center
340B ID
CHC24113-00
Entity Address
155 15th St
West Sacramento, CA 95691
Grant Number
H80CS24113
Participating Start Date
1/1/2018
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
JEFFERSON PHARMACY
Pharmacy Address
1029 JEFFERSON BLVD STE A
WEST SACRAMENTO, CA 95691-3344
Pharmacy Comments
Contract Details
Approval Date
4/11/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/19/2015
Agreement registered in error
Contacts
Covered Entity Signing Official
Tatyana Bak, COO
(916) 569-8484 Ext: 307
Contract Pharmacy Representative
Thy Pham, Owner
(916) 371-2022
Signed By Date
4/11/2014
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