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WAL-MART PHARMACY 10-0334
CHC22690-02 MACOUPIN, COUNTY OF
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Covered Entity Details
Entity Name
MACOUPIN, COUNTY OF
Subdivision Name
Columbian Boulevard Dental Clinic
Type
HRSA-Funded Health Center
340B ID
CHC22690-02
Entity Address
125 W Columbian Blvd S
Litchfield, IL 62056-3021
Grant Number
H80CS22690
Participating Start Date
7/1/2021
Last Recertification Date
2/18/2025
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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