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WAL-MART PHARMACY 10-0334
CHC22690-01 MACOUPIN, COUNTY OF
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Covered Entity Details
Entity Name
MACOUPIN, COUNTY OF
Subdivision Name
Macoupin County Public Health Clinic Site
Type
HRSA-Funded Health Center
340B ID
CHC22690-01
Entity Address
1115 E. Morgan Street
Carlinville, IL 62626-1430
Grant Number
H80CS22690
Participating Start Date
1/1/2020
Last Recertification Date
2/21/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0334
Pharmacy Address
18600 SHIPMAN BLACK TOP ROAD
CARLINVILLE, IL 62626
Pharmacy Comments
Contract Details
Approval Date
10/11/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Lori J Sanson, CFO
(217) 930-2282
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
10/11/2024
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