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IC PHARMACY LLC
CHC00341-00 PRIMECARE COMMUNITY HEALTH INC
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Covered Entity Details
Entity Name
PRIMECARE COMMUNITY HEALTH INC
Subdivision Name
PRIMECARE WEST TOWN
Type
HRSA-Funded Health Center
340B ID
CHC00341-00
Entity Address
1431 N Western Ave
Ste 406
Chicago, IL 60622
Grant Number
H80CS00341
Participating Start Date
4/1/2013
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
IC PHARMACY LLC
Pharmacy Address
AMAZON PHARMACY #004
34 35TH STREET
STE 4BSW, UNIT 28
BROOKLYN, NY 11232
Pharmacy Comments
Contract Details
Approval Date
7/11/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Michael C Holtrop, Chief Financial Officer
(616) 482-9892
Contract Pharmacy Representative
AMAZON PHARMACY
JOHN M LAVIN, MANAGING OFFICER
(602) 793-8552
Signed By Date
7/11/2024
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