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MISSOURI CVS PHARMACY, L.L.C.
CHC24098-21 SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF MEDICINE
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Covered Entity Details
Entity Name
SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF MEDICINE
Subdivision Name
SIU Center for Family Medicine - Care-A-Van
Type
HRSA-Funded Health Center
340B ID
CHC24098-21
Entity Address
300 W Oak St STE 100
Carbondale, IL 62901-1400
Grant Number
H80CS24098
Participating Start Date
4/1/2025
Last Recertification Date
Pharmacy Details
Pharmacy Name
MISSOURI CVS PHARMACY, L.L.C.
Pharmacy Address
DBA CVS/PHARMACY #10256
2161 WILLIAM ST.
CAPE GIRARDEAU, MO 63703
Pharmacy Comments
Contract Details
Approval Date
1/15/2025
Contract Begin Date
4/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Iris Elenora Wesley, CEO
(217) 757-8116
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
1/15/2025
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