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WAL-MART PHARMACY 10-2062
CH050220 INTERCARE COMMUNITY HEALTH NETWORK
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Covered Entity Details
Entity Name
INTERCARE COMMUNITY HEALTH NETWORK
Subdivision Name
INTERCARE ADMINISTRATION
Type
HRSA-Funded Health Center
340B ID
CH050220
Entity Address
50 Industrial Park Rd
Bangor, MI 49013-1246
Grant Number
H80CS00771
Participating Start Date
7/1/1998
Last Recertification Date
2/17/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2062
Pharmacy Address
1400 MALL DR
BENTON HARBOR, MI 49022
Pharmacy Comments
Contract Details
Approval Date
1/10/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
VELMA HENDERSHOTT, CEO
(269) 427-7937 Ext: 200
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/10/2014
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