Contract Pharmacy Details

WALMART PHARMACY 10-5169
CH010580 PROVIDENCE COMMUNITY HEALTH CENTERS, INC., THE

Covered Entity Details

Entity Name

PROVIDENCE COMMUNITY HEALTH CENTERS, INC., THE

Subdivision Name

PROVIDENCE COMMUNITY HEALTH CENTERS, INC.

Type

HRSA-Funded Health Center

340B ID

CH010580

Entity Address

375 Allens Ave
Providence, RI 02905-5010

Grant Number

H80CS00057

Participating Start Date

7/1/1996

Last Recertification Date

2/10/2025

Pharmacy Details

Pharmacy Name

WALMART PHARMACY 10-5169

Pharmacy Address

2252 NORTH 8TH STREET
SUITE A
ROGERS, AR 72756

Pharmacy Comments

Contract Details

Approval Date

4/12/2023

Contract Begin Date

7/1/2023

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

MERRILL THOMAS, CEO
(401) 444-0400 Ext: 3130

Contract Pharmacy Representative

Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719

Signed By Date

4/12/2023

340B Drug Pricing Program Database