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WAL-MART PHARMACY 10-0870
FQHCLA359C Southern Indiana Community Health Care Inc
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Covered Entity Details
Entity Name
Southern Indiana Community Health Care Inc
Subdivision Name
Crawford Family Medicine
Type
Health Center Program Look-Alike
340B ID
FQHCLA359C
Entity Address
5604 E. White Oak Lane
Marengo, IN 47140
Grant Number
LALCS31528
Participating Start Date
1/1/2018
Last Recertification Date
2/19/2019
Entity Termination Date
4/1/2020
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0870
Pharmacy Address
4040 NEWTON ST
JASPER, IN 47546
Pharmacy Comments
Contract Details
Approval Date
1/15/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Nancy Radcliff, CEO
(812) 723-3944
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
1/15/2018
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