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WALMART PHARMACY 10-5169
CHC22690-00 MACOUPIN, COUNTY OF
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Covered Entity Details
Entity Name
MACOUPIN, COUNTY OF
Subdivision Name
Macoupin County Maple Street Clinic
Type
HRSA-Funded Health Center
340B ID
CHC22690-00
Entity Address
109 E Maple St
Gillespie, IL 62033-1473
Grant Number
H80CS22690
Participating Start Date
7/1/2012
Last Recertification Date
2/18/2025
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
4/24/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Lori J Sanson, CFO
(217) 930-2282
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/24/2023
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