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WALGREEN CO
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
WALGREEN CO
Pharmacy Address
DBA: WALGREENS #12395
6607 STATE ROUTE 162
MARYVILLE, IL 62062
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
Walgreens
Christina Sayat, Analyst Client Relationship
(847) 946-4000
Signed By Date
10/11/2019
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