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GENOA HEALTHCARE LLC
FQHCLA458D INTERCOMMUNITY INC
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Covered Entity Details
Entity Name
INTERCOMMUNITY INC
Subdivision Name
InterCommunity Mobile Van #1
Type
Health Center Program Look-Alike
340B ID
FQHCLA458D
Entity Address
16 Coventry St Bldg
Hartford, CT 06112-1524
Grant Number
LALCS00170
Participating Start Date
4/1/2024
Last Recertification Date
2/25/2025
Pharmacy Details
Pharmacy Name
GENOA HEALTHCARE LLC
Pharmacy Address
287 MAIN STREET, SUITE A-2
EAST HARTFORD, CT 06118-1885
Pharmacy Comments
Contract Details
Approval Date
7/1/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Chad McDonald, Chief Medical Officer
(860) 569-5900
Contract Pharmacy Representative
Optum
Avani Patel, VP, 340B Operations
(763) 330-5555
Signed By Date
7/1/2024
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