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Walmart Pharmacy 10-7611
CH05102K HACKLEY COMMUNITY CARE CENTER INC
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Covered Entity Details
Entity Name
HACKLEY COMMUNITY CARE CENTER INC
Subdivision Name
Edgewood Elementary School
Type
HRSA-Funded Health Center
340B ID
CH05102K
Entity Address
3255 Pontaluna Rd Ste 0
Fruitport, MI 49415-9600
Grant Number
H80CS00684
Participating Start Date
1/1/2025
Last Recertification Date
2/12/2025
Pharmacy Details
Pharmacy Name
Walmart Pharmacy 10-7611
Pharmacy Address
2501 Perry Rd
Plainfield, IN 46168
Pharmacy Comments
Contract Details
Approval Date
10/9/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Valerie J Blondin, CFO
(231) 733-6657
Contract Pharmacy Representative
Walmart
Van Donn, Director of Contracting 340b
(303) 261-5549
Signed By Date
10/9/2024
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