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Walmart Pharmacy 10-7611
CH03122L N Penn Comprehensive Health Svcs
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Covered Entity Details
Entity Name
N Penn Comprehensive Health Svcs
Subdivision Name
Wellsboro Laurel Pediatric Center
Type
HRSA-Funded Health Center
340B ID
CH03122L
Entity Address
1B Main St
Wellsboro, PA 16901-1601
Grant Number
H80CS00682
Participating Start Date
1/1/2020
Last Recertification Date
3/5/2025
Pharmacy Details
Pharmacy Name
Walmart Pharmacy 10-7611
Pharmacy Address
2501 Perry Rd
Plainfield, IN 46168
Pharmacy Comments
Contract Details
Approval Date
10/16/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ronald M Gilbert, CFO
(570) 828-3869
Contract Pharmacy Representative
Walmart
Jodi Prohofsky, Sr. Director
(479) 277-1498
Signed By Date
10/16/2023
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