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BOND DRUG COMPANY OF ILLINOIS, L.L.C.
FQHCLA375B INNER CITY MUSLIM ACTION NETWORK
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Covered Entity Details
Entity Name
INNER CITY MUSLIM ACTION NETWORK
Subdivision Name
IMAN-Main Site
Type
Health Center Program Look-Alike
340B ID
FQHCLA375B
Entity Address
2744 W. 63rd St.
Chicago, IL 60629
Grant Number
LALCS31661
Participating Start Date
10/1/2018
Last Recertification Date
2/24/2020
Entity Termination Date
7/1/2020
Pharmacy Details
Pharmacy Name
BOND DRUG COMPANY OF ILLINOIS, L.L.C.
Pharmacy Address
WALGREENS # 16525
5401 S WENTWORTH AVE
SUITE 5A1
CHICAGO, IL 60609
Pharmacy Comments
Contract Details
Approval Date
1/3/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Constance Shabazz, Senior Director of Operations
(773) 434-4626
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
1/3/2019
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