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WALGREEN CO.
STD64106 BlaqOut, Inc.
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Covered Entity Details
Entity Name
BlaqOut, Inc.
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD64106
Entity Address
517 Campbell Street
Kansas City, MO 64106
Grant Number
NH25PS005142
Participating Start Date
4/1/2020
Last Recertification Date
5/13/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16072
3537 BROADWAY BLVD
KANSAS CITY, MO 64111
Pharmacy Comments
Contract Details
Approval Date
6/7/2022
Contract Begin Date
6/7/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
D. Rashaan Gilmore, President/CEO
(816) 866-0355
Contract Pharmacy Representative
Walgreen Co
Bradley Hedstrom, Account Manager Health Systems
(224) 515-6021
Signed By Date
6/7/2022
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