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WAL-MART PHARMACY 10-1734
CHC29834-01 PROMISE HEALTHCARE NFP
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Covered Entity Details
Entity Name
PROMISE HEALTHCARE NFP
Subdivision Name
Promise Healthcare Neil St
Type
HRSA-Funded Health Center
340B ID
CHC29834-01
Entity Address
821 S Neil St
Champaign, IL 61820-3055
Grant Number
H80CS29834
Participating Start Date
10/1/2016
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1734
Pharmacy Address
2610 NO PROSPECT AVE
CHAMPAIGN, IL 61821
Pharmacy Comments
Contract Details
Approval Date
4/5/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/31/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Deanna Lamb, Interim Chief Executive Officer
(910) 624-6289
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/5/2021
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