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WISCONSIN CVS PHARMACY, L.L.C.
CH057260 KENOSHA COMMUNITY HEALTH CENTER INC
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Covered Entity Details
Entity Name
KENOSHA COMMUNITY HEALTH CENTER INC
Subdivision Name
KENOSHA COMMUNITY HEALTH CENTER, INC.
Type
HRSA-Funded Health Center
340B ID
CH057260
Entity Address
4536 22nd Ave
Kenosha, WI 53140-5917
Grant Number
H80CS00662
Participating Start Date
4/1/2005
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
WISCONSIN CVS PHARMACY, L.L.C.
Pharmacy Address
CVS PHARMACY # 17326
9777 76TH ST
PLEASANT PRAIRIE, WI 53158
Pharmacy Comments
Contract Details
Approval Date
7/14/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Gary Moss, Chief Financial Officer
(262) 764-3619
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/14/2020
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