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Walmart Pharmacy 10-7611
CH057260D KENOSHA COMMUNITY HEALTH CENTER, INC.
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Covered Entity Details
Entity Name
KENOSHA COMMUNITY HEALTH CENTER, INC.
Subdivision Name
Kenosha Community Health Center Mobile Medical Unit
Type
HRSA-Funded Health Center
340B ID
CH057260D
Entity Address
6226 14th Ave
Kenosha, WI 53143-4413
Grant Number
H80CS00662
Participating Start Date
4/1/2023
Last Recertification Date
2/15/2024
Entity Termination Date
10/1/2024
Pharmacy Details
Pharmacy Name
Walmart Pharmacy 10-7611
Pharmacy Address
2501 Perry Rd
Plainfield, IN 46168
Pharmacy Comments
Contract Details
Approval Date
10/11/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Gary Moss, Chief Financial Officer
(262) 764-3619
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
10/11/2023
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