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TAILSTORM HEALTH INC
FQHC638290A PASCUA YAQUI HEALTH SERVICES DIVISION
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Covered Entity Details
Entity Name
PASCUA YAQUI HEALTH SERVICES DIVISION
Subdivision Name
PASCUA YAQUI HEALTH SERVICES DIVISION GUADALUPE
Type
Tribal Contract/Compact with IHS (P.L. 93-638)
340B ID
FQHC638290A
Entity Address
9405 S AVENIDA DEL YAQUI
GUADALUPE, AZ 85283-2529
Grant Number
Participating Start Date
7/1/2016
Last Recertification Date
2/28/2025
Pharmacy Details
Pharmacy Name
TAILSTORM HEALTH INC
Pharmacy Address
DBA VALLEY OF THE SUN PHARMACY
15600 N. BLACK CANYON HWY
SUITE B135
PHOENIX, AZ 85053
Pharmacy Comments
Contract Details
Approval Date
7/14/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/30/2020
Pharmacy closed
Contacts
Covered Entity Signing Official
Rosa M. Rivera, Administrator
(520) 879-6163
Contract Pharmacy Representative
Hartley Miller, COO
(602) 896-0454
Signed By Date
7/14/2017
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