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WAL-MART PHARMACY 10-1368
FQHCLA396 SHAWNEE MENTAL HEALTH CENTER INC
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Covered Entity Details
Entity Name
SHAWNEE MENTAL HEALTH CENTER INC
Subdivision Name
Portsmouth Clinic
Type
Health Center Program Look-Alike
340B ID
FQHCLA396
Entity Address
901 Washington St
Portsmouth, OH 45662-3944
Grant Number
LALCS32583
Participating Start Date
10/1/2019
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1368
Pharmacy Address
11217 STATE ROUTE 41
WEST UNION, OH 45693
Pharmacy Comments
Contract Details
Approval Date
10/4/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Cynthia Holstein, CEO
(740) 442-7670
Contract Pharmacy Representative
Walmart
George Flaherty, Sr Director, Payer Programs
(479) 739-1973
Signed By Date
10/4/2021
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