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GOOD VALUE PHARMACY LARSEN-MAYER
CH057260 KENOSHA COMMUNITY HEALTH CENTER INC
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Covered Entity Details
Entity Name
KENOSHA COMMUNITY HEALTH CENTER INC
Subdivision Name
KENOSHA COMMUNITY HEALTH CENTER, INC.
Type
HRSA-Funded Health Center
340B ID
CH057260
Entity Address
4536 22nd Ave
Kenosha, WI 53140-5917
Grant Number
H80CS00662
Participating Start Date
4/1/2005
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
GOOD VALUE PHARMACY LARSEN-MAYER
Pharmacy Address
3825 39TH AVE
SUITE 100
KENOSHA, WI 53144
Pharmacy Comments
Contract Details
Approval Date
12/30/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Gary Moss, Chief Financial Officer
(262) 764-3619
Contract Pharmacy Representative
PharmaForce
Michelle Tuttle, Implementation Manager
(740) 403-1023
Signed By Date
12/30/2021
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