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WAL-MART PHARMACY 10-2192
CHC26511-03 UPPER GREAT LAKES FAMILY HEALTH CENTER
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Covered Entity Details
Entity Name
UPPER GREAT LAKES FAMILY HEALTH CENTER
Subdivision Name
Ice Lake Family Health Center
Type
HRSA-Funded Health Center
340B ID
CHC26511-03
Entity Address
1500 W Ice Lake Rd
Iron River, MI 49935
Grant Number
H80CS26511
Participating Start Date
7/1/2014
Last Recertification Date
2/12/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2192
Pharmacy Address
995 RAZORBACK DR
HOUGHTON, MI 49931
Pharmacy Comments
Contract Details
Approval Date
1/4/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Donald A. Simila, CEO
(906) 481-8571
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
1/4/2021
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