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GOOD VALUE PHARMACY LARSEN-MAYER
CH057260A KENOSHA COMMUNITY HEALTH CENTER INC
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Covered Entity Details
Entity Name
KENOSHA COMMUNITY HEALTH CENTER INC
Subdivision Name
Kenosha Community Center Clinic
Type
HRSA-Funded Health Center
340B ID
CH057260A
Entity Address
1330 52nd Street STE 205
Kenosha, WI 53140-3236
Grant Number
H80CS00662
Participating Start Date
10/1/2013
Last Recertification Date
2/22/2023
Entity Termination Date
4/1/2024
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
Contract Termination Date
Termination Reason
4/1/2024
Covered Entity Terminated
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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