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WALMART PHARMACY 10-7243
FQHCLA364 BLACK RIVER HEALTH SERVICES INC
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Covered Entity Details
Entity Name
BLACK RIVER HEALTH SERVICES INC
Subdivision Name
Black River Family Practice
Type
Health Center Program Look-Alike
340B ID
FQHCLA364
Entity Address
301 South Campbell Street
Burgaw, NC 28425-5011
Grant Number
LALCS31614
Participating Start Date
4/1/2018
Last Recertification Date
2/17/2025
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-7243
Pharmacy Address
908 NC HIGHWAY 53 EAST
BURGAW, NC 28425
Pharmacy Comments
Contract Details
Approval Date
7/6/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/14/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Lee Ann Amann Amann, CEO
(910) 259-6973 Ext: 200
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
7/6/2018
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