Contract Pharmacy Details

WISCONSIN CVS PHARMACY, L.L.C.
STD53212 Holton Street Clinic, Inc

Covered Entity Details

Entity Name

Holton Street Clinic, Inc

Subdivision Name

Type

Sexually Transmitted Diseases

340B ID

STD53212

Entity Address

3251 N. HOLTON ST.
MILWAUKEE, WI 53212-2126

Grant Number

1U52PS005148

Participating Start Date

1/1/2008

Last Recertification Date

5/8/2024

Pharmacy Details

Pharmacy Name

WISCONSIN CVS PHARMACY, L.L.C.

Pharmacy Address

DBA CVS/PHARMACY #10163
2410 SOUTH 8TH ST.
WISCONSIN RAPIDS, WI 54494

Pharmacy Comments

Contract Details

Approval Date

1/3/2024

Contract Begin Date

4/1/2024

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

David Wenten, Executive Director
(414) 264-8800

Contract Pharmacy Representative

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

1/3/2024

340B Drug Pricing Program Database