Contract Pharmacy Details

WAL-MART PHARMACY 10-1756
FQHCLA278B CENTRAL NEIGHBORHOOD HEALTH FOUNDATION

Covered Entity Details

Entity Name

CENTRAL NEIGHBORHOOD HEALTH FOUNDATION

Subdivision Name

Central Neighborhood Health Foundation-Fontana

Type

Health Center Program Look-Alike

340B ID

FQHCLA278B

Entity Address

17695 Arrow Blvd.
Fontana, CA 92335

Grant Number

LALCS00088

Participating Start Date

1/1/2017

Last Recertification Date

1/26/2017

Entity Termination Date

4/1/2018

Pharmacy Details

Pharmacy Name

WAL-MART PHARMACY 10-1756

Pharmacy Address

17251 FOOTHILL BLVD
FONTANA, CA 92335

Pharmacy Comments

Contract Details

Approval Date

1/13/2018

Contract Begin Date

4/1/2018

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

4/1/2018
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Bassett Brown, Chief Executive Officer
(626) 252-5646

Contract Pharmacy Representative

Wal-mart
Laura Levine, Manager Contracting
(479) 204-8550

Signed By Date

1/13/2018

340B Drug Pricing Program Database