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PALMDALE MEDICAL PHARMACY
CHC26613-06 ANTELOPE VALLEY COMMUNITY CLINIC
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Covered Entity Details
Entity Name
ANTELOPE VALLEY COMMUNITY CLINIC
Subdivision Name
Antelope Valley Community Clinic - Palmdale East
Type
HRSA-Funded Health Center
340B ID
CHC26613-06
Entity Address
37926 47th St. East
Palmdale, CA 93552
Grant Number
H80CS26613
Participating Start Date
7/1/2017
Last Recertification Date
2/1/2019
Entity Termination Date
10/1/2019
Pharmacy Details
Pharmacy Name
PALMDALE MEDICAL PHARMACY
Pharmacy Address
540 W PALMDALE BLVD #A
PALMDALE, CA 93551-4232
Pharmacy Comments
Contract Details
Approval Date
10/16/2017
Contract Begin Date
1/1/2018
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
Palmdale Medical Pharmacy
Ivan Law, Pharmacy Manager
(661) 267-2638
Signed By Date
10/16/2017
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