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WALMART PHARMACY 10-5169
FQHCLA402 Good Samaritan Family Health Center Inc.
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Covered Entity Details
Entity Name
Good Samaritan Family Health Center Inc.
Subdivision Name
Family Health Center
Type
Health Center Program Look-Alike
340B ID
FQHCLA402
Entity Address
1027 Washington Avenue
Suite B
Vincennes, IN 47591
Grant Number
LALCS33817
Participating Start Date
1/1/2020
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
7/17/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jennifer Emmons, CEO
(812) 494-7800
Contract Pharmacy Representative
Walmart
Van Donn, Director of Contracting 340b
(303) 261-5549
Signed By Date
7/17/2023
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