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WAL-MART PHARMACY 10-1993
FQHCLA342B Trillium Health, Inc.
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Covered Entity Details
Entity Name
Trillium Health, Inc.
Subdivision Name
Trillium Health Mobile Access Clinic (MAC)
Type
Health Center Program Look-Alike
340B ID
FQHCLA342B
Entity Address
170 Science Pkwy
Rochester, NY 14620-4251
Grant Number
LALCS00182
Participating Start Date
4/1/2020
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1993
Pharmacy Address
6265 BROCKPORT SPENCERPORT RD
BROCKPORT, NY 14420
Pharmacy Comments
Contract Details
Approval Date
1/14/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/7/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Gregory Clyde Ewing, S.V.P. Compliance, Privacy, Technology & Regulatory Affairs/CCO
(585) 545-7218
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
1/14/2021
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