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WAL-MART PHARMACY 10-1028
CH051833A Heartland Community Health Clinic DBA: Heartland Health Services
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Covered Entity Details
Entity Name
Heartland Community Health Clinic DBA: Heartland Health Services
Subdivision Name
Garden
Type
HRSA-Funded Health Center
340B ID
CH051833A
Entity Address
1701 W Garden St
Peoria, IL 61605
Grant Number
H80CS02457
Participating Start Date
1/1/2004
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1028
Pharmacy Address
401 RIVER ROAD
EAST PEORIA, IL 61611
Pharmacy Comments
Contract Details
Approval Date
4/3/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
CHARLES BANDOIAN, CEO
(309) 680-7657
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
4/3/2017
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