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WAL-MART PHARMACY 10-2950
CHC26613-00 ANTELOPE VALLEY COMMUNITY CLINIC
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Covered Entity Details
Entity Name
ANTELOPE VALLEY COMMUNITY CLINIC
Subdivision Name
Antelope Valley Community Clinic - Health and Wellness Center
Type
HRSA-Funded Health Center
340B ID
CHC26613-00
Entity Address
45104 10th St W
Lancaster, CA 93534-2310
Grant Number
H80CS26613
Participating Start Date
4/1/2014
Last Recertification Date
2/1/2019
Entity Termination Date
10/1/2019
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2950
Pharmacy Address
37140 47TH STREET EAST
PALMDALE, CA 93552
Pharmacy Comments
Contract Details
Approval Date
4/16/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
James A. Cook, CEO
(661) 942-2391
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
4/16/2014
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