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Walmart Pharmacy 10-7611
CH093070 MOUNTAIN PARK HEALTH CENTER
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Covered Entity Details
Entity Name
MOUNTAIN PARK HEALTH CENTER
Subdivision Name
Mountain Park Health Center - Baseline
Type
HRSA-Funded Health Center
340B ID
CH093070
Entity Address
635 E Baseline Rd
Phoenix, AZ 85042-6551
Grant Number
H80CS00141
Participating Start Date
10/1/1996
Last Recertification Date
2/13/2025
Pharmacy Details
Pharmacy Name
Walmart Pharmacy 10-7611
Pharmacy Address
2501 Perry Rd
Plainfield, IN 46168
Pharmacy Comments
Contract Details
Approval Date
10/4/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
John R. Swagert, CEO
(602) 323-3470
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/4/2023
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