Contract Pharmacy Details

WALGREEN CO
CH05320AF HealthNet, Inc.

Covered Entity Details

Entity Name

HealthNet, Inc.

Subdivision Name

KIPP Indy Legacy Clinic

Type

HRSA-Funded Health Center

340B ID

CH05320AF

Entity Address

2255 Ralston Ave Rm 106
Rm 106
Indianapolis, IN 46218-3444

Grant Number

H80CS00114

Participating Start Date

1/1/2020

Last Recertification Date

2/3/2024

Entity Termination Date

1/1/2025

Pharmacy Details

Pharmacy Name

WALGREEN CO

Pharmacy Address

DBA: WALGREENS #10487
6745 E SOUTHPORT ROAD
INDIANAPOLIS, IN 46237-9728

Pharmacy Comments

Contract Details

Approval Date

10/13/2023

Contract Begin Date

1/1/2024

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

1/1/2025
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Varon Edward Cantrell, Chief Medical Officer
(317) 957-2015

Contract Pharmacy Representative

Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663

Signed By Date

10/13/2023

340B Drug Pricing Program Database