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WALGREEN EASTERN CO., INC.
FQHCLA360 Upstate Family Health Center, Inc.
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Covered Entity Details
Entity Name
Upstate Family Health Center, Inc.
Subdivision Name
Upstate Family Health Center, Inc.
Type
Health Center Program Look-Alike
340B ID
FQHCLA360
Entity Address
1001 Noyes Street
Utica, NY 13502-4400
Grant Number
LALCS31538
Participating Start Date
4/1/2018
Last Recertification Date
1/28/2020
Entity Termination Date
7/1/2020
Pharmacy Details
Pharmacy Name
WALGREEN EASTERN CO., INC.
Pharmacy Address
WALGREENS
1143 MOHAWK ST
UTICA, NY 13501
Pharmacy Comments
Contract Details
Approval Date
1/14/2019
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
Jaime Oot, Project Manager
(315) 624-9470 Ext: 260
Contract Pharmacy Representative
Walgreen
krystal mobley, Sr Analyst
(847) 964-8918
Signed By Date
1/14/2019
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