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Walmart Pharmacy 10-7611
FQHCLA424 Monticello Medical Associates, Inc
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Covered Entity Details
Entity Name
Monticello Medical Associates, Inc
Subdivision Name
Monticello Medical Associates
Type
Health Center Program Look-Alike
340B ID
FQHCLA424
Entity Address
1 S Creek Dr Ste 102
Monticello, KY 42633-9472
Grant Number
LALCS40210
Participating Start Date
7/1/2021
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
10/10/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
ROBERT PARMELEE, CEO
(606) 348-3365 Ext: 240
Contract Pharmacy Representative
Walmart
Van Donn, Director of Contracting 340b
(303) 261-5549
Signed By Date
10/10/2023
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