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RALPHS GROCERY CO
CH09100AA Northeast Valley Health Corporation
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Covered Entity Details
Entity Name
Northeast Valley Health Corporation
Subdivision Name
Maclay Wellness Center
Type
HRSA-Funded Health Center
340B ID
CH09100AA
Entity Address
12451 W. Gain Street
Pacoima, CA 91331-1642
Grant Number
H80CS00139
Participating Start Date
1/1/2021
Last Recertification Date
2/11/2025
Pharmacy Details
Pharmacy Name
RALPHS GROCERY CO
Pharmacy Address
DBA: RALPHS #721
22333 SHERMAN WAY
CANOGA PARK, CA 91303
Pharmacy Comments
Contract Details
Approval Date
1/12/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Kimberly Wyard, Chief Executive Officer
(818) 898-1388 Ext: 41620
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
1/12/2018
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