Contract Pharmacy Details

SULLIVAN DRUG CO
CHC22690-01 MACOUPIN, COUNTY OF

Covered Entity Details

Entity Name

MACOUPIN, COUNTY OF

Subdivision Name

Macoupin County Public Health Clinic Site

Type

HRSA-Funded Health Center

340B ID

CHC22690-01

Entity Address

1115 E. Morgan Street
Carlinville, IL 62626-1430

Grant Number

H80CS22690

Participating Start Date

1/1/2020

Last Recertification Date

2/21/2025

Pharmacy Details

Pharmacy Name

SULLIVAN DRUG CO

Pharmacy Address

101 E MAIN ST
STAUNTON, IL 62088

Pharmacy Comments

Contract Details

Approval Date

10/11/2019

Contract Begin Date

1/1/2020

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Kent Tarro, CEO
(217) 825-6705

Contract Pharmacy Representative

Sullivans Drugs
Maurice Sullivan, CEO
(217) 839-2909

Signed By Date

10/11/2019