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WAL-MART PHARMACY 10-2563
CHC33650-05 Southern Indiana Community Health Care Inc
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Covered Entity Details
Entity Name
Southern Indiana Community Health Care Inc
Subdivision Name
SICHC Bedford Temporary Site
Type
HRSA-Funded Health Center
340B ID
CHC33650-05
Entity Address
2512 Q Street
Bedford, IN 47421
Grant Number
H80CS33650
Participating Start Date
4/1/2023
Last Recertification Date
2/10/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2563
Pharmacy Address
735 NORTH GOSPEL ST
PAOLI, IN 47454
Pharmacy Comments
Contract Details
Approval Date
7/10/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Nancy Radcliff, CEO
(812) 723-3944
Contract Pharmacy Representative
Wal-mart
Laura Levine, Manager Contracting
(479) 204-8550
Signed By Date
7/10/2023
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