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WAL-MART PHARMACY 10-0892
CH07055A Primary Health Care, Inc.
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Covered Entity Details
Entity Name
Primary Health Care, Inc.
Subdivision Name
Primary Health Care - Bery Engebretsen Clinic
Type
HRSA-Funded Health Center
340B ID
CH07055A
Entity Address
2353 SE 14th St
Des Moines, IA 50320-1109
Grant Number
H80CS00715
Participating Start Date
7/1/2002
Last Recertification Date
2/11/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0892
Pharmacy Address
1002 SE NATIONAL DRIVE
ANKENY, IA 50021
Pharmacy Comments
Contract Details
Approval Date
1/13/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/15/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kelly Huntsman, CEO
(515) 248-1441
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/13/2020
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