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WAL-MART PHARMACY 10-3896
STD85004 Prisma Community Care
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Covered Entity Details
Entity Name
Prisma Community Care
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD85004
Entity Address
1101 N Central Ave
Suite 200
Phoenix, AZ 85004
Grant Number
5 NU62PS924676-03-00
Participating Start Date
1/1/2019
Last Recertification Date
5/5/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3896
Pharmacy Address
21655 N. LAKE PLEASANT PKWY
PEORIA, AZ 85382
Pharmacy Comments
Contract Details
Approval Date
1/5/2023
Contract Begin Date
1/13/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jessyca Leach, Executive Director
(602) 595-8115
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/5/2023
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