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MEIJER STORES LIMITED PARTNERSHIP
CH051741K Shalom Health Care Center, Inc.
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Covered Entity Details
Entity Name
Shalom Health Care Center, Inc.
Subdivision Name
Shalom Health Care Center PHC Mobile Clinic
Type
HRSA-Funded Health Center
340B ID
CH051741K
Entity Address
3400 LAFAYETTE RD STE 200
INDIANAPOLIS, IN 46222-1147
Grant Number
H80CS00880
Participating Start Date
1/1/2020
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
MEIJER STORES LIMITED PARTNERSHIP
Pharmacy Address
D/B/A MEIJER PHARMACY #463
1515 PROFIT DR.
FORT WAYNE, IN 46808
Pharmacy Comments
Contract Details
Approval Date
10/16/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/29/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Leonardo R. Ortega, Executive Director/CEO
(317) 291-7422 Ext: 1105
Contract Pharmacy Representative
Meijer
Kevin Hurn, Dir, Pharmacy Procurement and New Business
(616) 791-5185
Signed By Date
10/15/2019
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