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HOOK-SUPERX, L.L.C.
FQHCLA392A Edgewater Systems For Balanced Living, Inc.
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Covered Entity Details
Entity Name
Edgewater Systems For Balanced Living, Inc.
Subdivision Name
Edgewater Health
Type
Health Center Program Look-Alike
340B ID
FQHCLA392A
Entity Address
1100 W 6th Ave
Gary, IN 46402-1711
Grant Number
LALCS33108
Participating Start Date
10/1/2019
Last Recertification Date
2/17/2025
Pharmacy Details
Pharmacy Name
HOOK-SUPERX, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 06912
11115 WEST 133RD STREET
CEDAR LAKE, IN 46303
Pharmacy Comments
Contract Details
Approval Date
4/1/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Danita A Johnson, CEO
(219) 806-3556
Contract Pharmacy Representative
WellPartner
Anthony McEeachern, Anthony McEachern
(315) 314-1802
Signed By Date
4/1/2024
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