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WAL-MART PHARMACY 10-5315
FQHCLA119 Community Clinical Services, Inc.
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Covered Entity Details
Entity Name
Community Clinical Services, Inc.
Subdivision Name
B Street Health Center
Type
Health Center Program Look-Alike
340B ID
FQHCLA119
Entity Address
57 Birch Street
Lewiston, ME 04240-7415
Grant Number
LALCS00085
Participating Start Date
4/1/2001
Last Recertification Date
3/3/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
7/15/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Coleen Lynn Elias, CEO/CFO
(207) 513-3897
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
7/15/2020
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