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WISCONSIN CVS PHARMACY, L.L.C.
STD53212 Holton Street Clinic, Inc
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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
CVS PHARMACY # 17015
1501 MILLER PARK WAY
WEST MILWAUKEE, WI 53214
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
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