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WAL-MART PHARMACY 10-5444
CHC26511-11 Upper Great Lakes Family Health Center
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Covered Entity Details
Entity Name
Upper Great Lakes Family Health Center
Subdivision Name
Marquette Family Health Center
Type
HRSA-Funded Health Center
340B ID
CHC26511-11
Entity Address
1414 W Fair Ave
Ste 249
Marquette, MI 49855
Grant Number
H80CS26511
Participating Start Date
6/10/2020
Last Recertification Date
2/12/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5444
Pharmacy Address
10305 COUNTRY CLUB ROAD
IRONWOOD, MI 49938
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
1/1/2021
Agreement registered in error
Contacts
Covered Entity Signing Official
Donald A. Simila, CEO
(906) 481-8571
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
7/1/2020
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