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CYPRESS FAIRBANKS-ACP
FQHCLA348 COLLIN COUNTY ADULT CLINIC
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Covered Entity Details
Entity Name
COLLIN COUNTY ADULT CLINIC
Subdivision Name
Collin County Adult Clinic
Type
Health Center Program Look-Alike
340B ID
FQHCLA348
Entity Address
2520 K Ave STE 100
Plano, TX 75074-5342
Grant Number
LALCS00156
Participating Start Date
7/1/2017
Last Recertification Date
3/6/2018
Entity Termination Date
4/1/2019
Pharmacy Details
Pharmacy Name
CYPRESS FAIRBANKS-ACP
Pharmacy Address
CYPRESS FAIRBANKS-ACP
11302 FALLBROOK DR
STE 104
HOUSTON, TX 77065-5270
Pharmacy Comments
Contract Details
Approval Date
4/17/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Patricia Sumler, Executive Director
(972) 423-4944
Contract Pharmacy Representative
Coty Leal, Manager
(936) 537-4698
Signed By Date
4/17/2017
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