Contract Pharmacy Details

MADERA MEDICAL PHARMACY
FQHCLA338 HORISONS UNLIMITED

Covered Entity Details

Entity Name

HORISONS UNLIMITED

Subdivision Name

Horisons Unlimited Mariposa

Type

Health Center Program Look-Alike

340B ID

FQHCLA338

Entity Address

5320 STATE HIGHWAY 49 N
MARIPOSA, CA 95338-9588

Grant Number

LALCS00172

Participating Start Date

1/1/2016

Last Recertification Date

1/27/2017

Entity Termination Date

10/12/2017

Pharmacy Details

Pharmacy Name

MADERA MEDICAL PHARMACY

Pharmacy Address

LBN- MEL PHARM INC
402 S. MADERA AVENUE
SUITE A
MADERA, CA 93637

Pharmacy Comments

Contract Details

Approval Date

10/15/2016

Contract Begin Date

1/1/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/12/2017
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Sandy Haar, CEO
(209) 201-2099

Contract Pharmacy Representative

Lori Pryce, Managing Director
(559) 674-8553

Signed By Date

10/15/2016

340B Drug Pricing Program Database