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WALMART PHARMACY 10-4653
CH0814640 CHEYENNE HEALTH AND WELLNESS CENTER
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Covered Entity Details
Entity Name
CHEYENNE HEALTH AND WELLNESS CENTER
Subdivision Name
CHEYENNE HEALTH AND WELLNESS CENTER
Type
HRSA-Funded Health Center
340B ID
CH0814640
Entity Address
2508 EAST FOX FARM ROAD STE 1-1A
CHEYENNE, WY 82007
Grant Number
H80CS04196
Participating Start Date
7/1/2005
Last Recertification Date
2/21/2025
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-4653
Pharmacy Address
580 LIVINGSTON AVENUE
CHEYENNE, WY 82007
Pharmacy Comments
Contract Details
Approval Date
1/10/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
David W. Squires, CEO
(307) 635-3618 Ext: 1070
Contract Pharmacy Representative
Wal-Mart
Marcus Osbourne, VP of Health and Wellness Transformation
(479) 204-9374
Signed By Date
1/10/2017
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