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WALGREEN CO.
STD84109 Hope on T.T.a.P.P.
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Covered Entity Details
Entity Name
Hope on T.T.a.P.P.
Subdivision Name
Type
Sexually Transmitted Diseases
340B ID
STD84109
Entity Address
2468 E EVERGREEN AVE
Salt Lake City, UT 84109-3008
Grant Number
5NU51PS0051700400
Participating Start Date
4/1/2023
Last Recertification Date
5/8/2025
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16481
201 S 1300 E STE 101
SALT LAKE CITY, UT 84102
Pharmacy Comments
Contract Details
Approval Date
7/17/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Sequan Kolibas, Executive Director
(801) 808-4260
Contract Pharmacy Representative
Walgreen Co
Stephen Perius, Pharmacy Representative
(323) 251-4417
Signed By Date
7/17/2023
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