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WAL-MART CENTRAL FILL 10-2670
FQHCLA346D Highland Health Providers Corporation
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Covered Entity Details
Entity Name
Highland Health Providers Corporation
Subdivision Name
Highland Health Providers - Rocky Fork Medical Center
Type
Health Center Program Look-Alike
340B ID
FQHCLA346D
Entity Address
11130 N Shore Dr
Hillsboro, OH 45133-9751
Grant Number
LALCS00180
Participating Start Date
10/1/2019
Last Recertification Date
2/10/2020
Entity Termination Date
7/1/2020
Pharmacy Details
Pharmacy Name
WAL-MART CENTRAL FILL 10-2670
Pharmacy Address
608 SPRING HILL DR # 3 SUITE 300
SPRING, TX 77386
Pharmacy Comments
Contract Details
Approval Date
9/5/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Amanda M Warix, Executive Director
(937) 393-5753
Contract Pharmacy Representative
Wal-mart
Laura Levine, Manager Contracting
(479) 204-8550
Signed By Date
7/2/2019
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