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WAL-MART PHARMACY 10-5444
CHC26511-05 UPPER GREAT LAKES FAMILY HEALTH CENTER
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Covered Entity Details
Entity Name
UPPER GREAT LAKES FAMILY HEALTH CENTER
Subdivision Name
Ontonagon Family Health Center
Type
HRSA-Funded Health Center
340B ID
CHC26511-05
Entity Address
751 7th Avenue South
Ontonagon, MI 49953
Grant Number
H80CS26511
Participating Start Date
7/1/2014
Last Recertification Date
2/12/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5444
Pharmacy Address
10305 COUNTRY CLUB ROAD
IRONWOOD, MI 49938
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
10/1/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Donald A. Simila, CEO
(906) 481-8571
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
6/18/2014
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