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GENOA HEALTHCARE LLC
CHC26568-00 SOUTHLAKE COMMUNITY MENTAL HEALTH CENTER
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Covered Entity Details
Entity Name
SOUTHLAKE COMMUNITY MENTAL HEALTH CENTER
Subdivision Name
Regional Health Clinic, Homeless Site
Type
HRSA-Funded Health Center
340B ID
CHC26568-00
Entity Address
527 State St
Hammond, IN 46320-1533
Grant Number
H80CS26568
Participating Start Date
4/1/2014
Last Recertification Date
2/7/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
GENOA HEALTHCARE LLC
Pharmacy Address
8555 TAFT STREET
MERRILLVILLE, IN 46410
Pharmacy Comments
Contract Details
Approval Date
4/14/2020
Contract Begin Date
5/5/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Amy Lopez, Executive Director
(219) 671-6047
Contract Pharmacy Representative
Genoa Healthcare
Frank Gordon, Region 25 Director of Operations
(260) 415-7746 Ext: 2604157746
Signed By Date
4/14/2020
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