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WAL-MART PHARMACY 10-0986
CHC28361-06 Summit Community Care Clinic
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Covered Entity Details
Entity Name
Summit Community Care Clinic
Subdivision Name
Lake County High School
Type
HRSA-Funded Health Center
340B ID
CHC28361-06
Entity Address
1000 W. 4th Street
Leadville, CO 80461
Grant Number
H80CS28361
Participating Start Date
7/1/2019
Last Recertification Date
2/11/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0986
Pharmacy Address
840 SUMMIT BLVD.
P.O. BOX 4220
FRISCO, CO 80443
Pharmacy Comments
Contract Details
Approval Date
1/9/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Daniel Brian Becker, CEO
(970) 424-4899
Contract Pharmacy Representative
Walmart
Jodi Prohofsky, Sr. Director
(479) 277-1498
Signed By Date
1/9/2024
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