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WAL-MART PHARMACY 10-3304
CHC26514-00 TRIAD ADULT AND PEDIATRIC MEDICINE, INC.
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Covered Entity Details
Entity Name
TRIAD ADULT AND PEDIATRIC MEDICINE, INC.
Subdivision Name
TAPM Pediatrics at Wendover
Type
HRSA-Funded Health Center
340B ID
CHC26514-00
Entity Address
1046 E Wendover Ave
Greensboro, NC 27405-6712
Grant Number
H80CS26514
Participating Start Date
1/1/2015
Last Recertification Date
2/12/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3304
Pharmacy Address
1624 NC #14 HWY
REIDSVILLE, NC 27320
Pharmacy Comments
Contract Details
Approval Date
4/12/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/30/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Michelle Lewis, CEO
(336) 355-9715
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
4/12/2017
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