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WAL-MART PHARMACY 10-1445
FQHCLA275 FAMILY HEALTH SERVICES OF ERIE COUNTY
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Covered Entity Details
Entity Name
FAMILY HEALTH SERVICES OF ERIE COUNTY
Subdivision Name
Type
Health Center Program Look-Alike
340B ID
FQHCLA275
Entity Address
1912 HAYES AVENUE
SANDUSKY, OH 44870
Grant Number
LALCS00098
Participating Start Date
4/1/2011
Last Recertification Date
2/16/2015
Entity Termination Date
10/1/2015
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1445
Pharmacy Address
2826 E. HARBOR ROAD
PORT CLINTON, OH 43452
Pharmacy Comments
Contract Details
Approval Date
4/27/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2015
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Wilson Forney, Chief Executive Officer
(419) 502-2818
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
4/27/2015
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