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WISCONSIN CVS PHARMACY, L.L.C.
CH057260A KENOSHA COMMUNITY HEALTH CENTER INC
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Covered Entity Details
Entity Name
KENOSHA COMMUNITY HEALTH CENTER INC
Subdivision Name
Kenosha Community Center Clinic
Type
HRSA-Funded Health Center
340B ID
CH057260A
Entity Address
1330 52nd Street STE 205
Kenosha, WI 53140-3236
Grant Number
H80CS00662
Participating Start Date
10/1/2013
Last Recertification Date
2/22/2023
Entity Termination Date
4/1/2024
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
Contract Termination Date
Termination Reason
4/1/2024
Covered Entity Terminated
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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