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WAL-MART PHARMACY 10-2572
CH05290K COMMUNITY ACTION COMMITTEE OF PIKE COUNTY, THE
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Covered Entity Details
Entity Name
COMMUNITY ACTION COMMITTEE OF PIKE COUNTY, THE
Subdivision Name
Broadway Street Clinic
Type
HRSA-Funded Health Center
340B ID
CH05290K
Entity Address
621 Broadway Street
Portsmouth, OH 45662
Grant Number
H80CS00399
Participating Start Date
10/1/2014
Last Recertification Date
2/13/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2572
Pharmacy Address
990 WEST EMMITT AVENUE
WAVERLY, OH 45690
Pharmacy Comments
Contract Details
Approval Date
7/21/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/2/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
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