Contract Pharmacy Details

WAL-MART PHARMACY 10-2951
CHC26613-00 ANTELOPE VALLEY COMMUNITY CLINIC

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 10-2951

Pharmacy Address

1731 EAST AVENUE J
LANCASTER (E), CA 93535

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

340B Drug Pricing Program Database