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WALGREEN CO.
CH03224R PENINSULA INSTITUTE FOR COMMUNITY HEALTH, INC
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Covered Entity Details
Entity Name
PENINSULA INSTITUTE FOR COMMUNITY HEALTH, INC
Subdivision Name
Southeastern Virginia Health System @ Western Tidewater Community Services Board
Type
HRSA-Funded Health Center
340B ID
CH03224R
Entity Address
5268 Godwin Boulevard
Suffolk, VA 23434-8027
Grant Number
H80CS00073
Participating Start Date
7/1/2016
Last Recertification Date
1/31/2022
Entity Termination Date
4/1/2023
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS #10416
2902 GODWIN BLVD.
SUFFOLK, VA 23434-8040
Pharmacy Comments
Contract Details
Approval Date
4/7/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Stephanie Gomez, 340B Operations Analyst
(847) 964-8785
Signed By Date
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