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WAL-MART PHARMACY 10-4293
CH09307S Mountain Park Health Center
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Covered Entity Details
Entity Name
Mountain Park Health Center
Subdivision Name
Mountain Park Health Center - Balsz
Type
HRSA-Funded Health Center
340B ID
CH09307S
Entity Address
1300 N 48th Street
Phoenix, AZ 85008
Grant Number
H80CS00141
Participating Start Date
11/3/2021
Last Recertification Date
2/13/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-4293
Pharmacy Address
2435 EAST BASELINE ROAD
PHOENIX, AZ 85042
Pharmacy Comments
Contract Details
Approval Date
4/12/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
John R. Swagert, CEO
(602) 323-3470
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/12/2024
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