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HIGHLAND PARK CVS, L.L.C.
CHC22690-00 MACOUPIN, COUNTY OF
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Covered Entity Details
Entity Name
MACOUPIN, COUNTY OF
Subdivision Name
Macoupin County Maple Street Clinic
Type
HRSA-Funded Health Center
340B ID
CHC22690-00
Entity Address
109 E Maple St
Gillespie, IL 62033-1473
Grant Number
H80CS22690
Participating Start Date
7/1/2012
Last Recertification Date
2/18/2025
Pharmacy Details
Pharmacy Name
HIGHLAND PARK CVS, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 06932
608 S. MAIN ST.
HILLSBORO, IL 62049
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
CVS
Charles Basralian, Acct Manager
(401) 772-7343
Signed By Date
10/11/2019
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