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GOOD VALUE PHARMACY LARSEN-MAYER
CH057260G KENOSHA COMMUNITY HEALTH CENTER, INC.
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Covered Entity Details
Entity Name
KENOSHA COMMUNITY HEALTH CENTER, INC.
Subdivision Name
Kenosha Community Health Center, Inc.
Type
HRSA-Funded Health Center
340B ID
CH057260G
Entity Address
903 S 2nd St
Silver Lake, WI 53170-1747
Grant Number
H80CS00662
Participating Start Date
4/1/2023
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
GOOD VALUE PHARMACY LARSEN-MAYER
Pharmacy Address
3825 39TH AVE
SUITE 100
KENOSHA, WI 53144
Pharmacy Comments
Contract Details
Approval Date
7/11/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
John Stampfl, Controller
(262) 771-3561
Contract Pharmacy Representative
PharmaForce
Michelle Tuttle, Implementation Manager
(740) 403-1023
Signed By Date
7/11/2024
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