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AGELESS RX SYSTEMS LLC
CHC22690-00 MACOUPIN, COUNTY OF
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Covered Entity Details
Entity Name
MACOUPIN, COUNTY OF
Subdivision Name
Macoupin County Maple Street Clinic
Type
HRSA-Funded Health Center
340B ID
CHC22690-00
Entity Address
109 E Maple St
Gillespie, IL 62033-1473
Grant Number
H80CS22690
Participating Start Date
7/1/2012
Last Recertification Date
2/18/2025
Pharmacy Details
Pharmacy Name
AGELESS RX SYSTEMS LLC
Pharmacy Address
DBA SUILLIVANS DRUGS OF GILLESPIE
103 N JERSEY ST
SUITE 101
GILLESPIE, IL 62033
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
Lori J Sanson, CFO
(217) 930-2282
Contract Pharmacy Representative
Ageless RX Systems LLC
TJ Allan, Owner
(217) 839-2877
Signed By Date
4/12/2024
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