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MARYVILLE PHARMACY
CH05332BX Southern Illinois Health Care Foundation, Inc.
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Covered Entity Details
Entity Name
Southern Illinois Health Care Foundation, Inc.
Subdivision Name
Central Collinsville Health Center
Type
HRSA-Funded Health Center
340B ID
CH05332BX
Entity Address
80 Burlington Street
Collinsville, IL 62234-4931
Grant Number
H80CS00195
Participating Start Date
1/1/2010
Last Recertification Date
2/13/2017
Entity Termination Date
4/1/2017
Pharmacy Details
Pharmacy Name
MARYVILLE PHARMACY
Pharmacy Address
HEALTH MANAGEMENT ZONE, INC.
2700 N CENTER ST
MARYVILLE, IL 62062-5624
Pharmacy Comments
Contract Details
Approval Date
6/21/2012
Contract Begin Date
6/21/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2017
Contacts
Covered Entity Signing Official
Larry McCulley, President
(618) 332-0694 Ext: 155
Contract Pharmacy Representative
Gary Ceretto, Owner
(618) 288-7474
Signed By Date
6/4/2012
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