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WAL-MART PHARMACY 10-5617
CH057440 PCC COMMUNITY WELLNESS CENTER
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Covered Entity Details
Entity Name
PCC COMMUNITY WELLNESS CENTER
Subdivision Name
PCC Lake Street Family Health Center
Type
HRSA-Funded Health Center
340B ID
CH057440
Entity Address
14 Lake St
Oak Park, IL 60302-2606
Grant Number
H80CS00276
Participating Start Date
7/1/1997
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5617
Pharmacy Address
4626 W DIVERSEY AVE.
CHICAGO, IL 60639
Pharmacy Comments
Contract Details
Approval Date
10/3/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Robert Urso, President & CEO
(708) 524-7686
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/3/2018
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