Contract Pharmacy Details

FAGEN PHARMACY #36
CH0530920 HEALTHLINC INC

Covered Entity Details

Entity Name

HEALTHLINC INC

Subdivision Name

HealthLinc Valparaiso

Type

HRSA-Funded Health Center

340B ID

CH0530920

Entity Address

1001 Sturdy Rd
Valparaiso, IN 46383-4126

Grant Number

H80CS06662

Participating Start Date

1/1/2004

Last Recertification Date

2/19/2025

Pharmacy Details

Pharmacy Name

FAGEN PHARMACY #36

Pharmacy Address

1350 BROADWAY STREET
GARY, IN 46407

Pharmacy Comments

4/30/10 UPDATED ADDR (WAS 504 BROADWAY)

Contract Details

Approval Date

4/30/2010

Contract Begin Date

6/1/2010

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

9/16/2017
Ownership change

Contacts

Covered Entity Signing Official

BETH WROBEL, CEO
(219) 465-9500

Contract Pharmacy Representative

Gerald A. Fagen, President
(219) 987-6468

Signed By Date

4/7/2010