Contract Pharmacy Details

HIGHLAND PARK CVS, L.L.C.
CHC22690-00 MACOUPIN, COUNTY OF

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 # 06832
2422 COLLEGE AVE.
ALTON, IL 62002

Pharmacy Comments

Contract Details

Approval Date

7/1/2020

Contract Begin Date

10/1/2020

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

11/21/2023
Pharmacy closed

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

7/1/2020

340B Drug Pricing Program Database