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WAL-MART PHARMACY 10-2079
CHC26511-02 UPPER GREAT LAKES FAMILY HEALTH CENTER
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Covered Entity Details
Entity Name
UPPER GREAT LAKES FAMILY HEALTH CENTER
Subdivision Name
Calumet Family Health Center
Type
HRSA-Funded Health Center
340B ID
CHC26511-02
Entity Address
56901 South Sixth Street, Suites 1 and 2
Calumet, MI 49913-2946
Grant Number
H80CS26511
Participating Start Date
4/1/2014
Last Recertification Date
2/2/2017
Entity Termination Date
4/1/2017
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2079
Pharmacy Address
3225 U.S. HWY 41 WEST
MARQUETTE, MI 49855
Pharmacy Comments
Contract Details
Approval Date
6/18/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2017
Contacts
Covered Entity Signing Official
Donald A. Simila, CEO
(906) 481-8571
Contract Pharmacy Representative
Wal--Mart
Marcus Osborne, Sales & Contracting
(479) 204-8452
Signed By Date
6/18/2014
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