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WAL-MART PHARMACY 10-4511
CAH141319-00 Henry District Hospital
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Covered Entity Details
Entity Name
Henry District Hospital
Subdivision Name
Hammond Henry Hospital
Type
Critical Access Hospital
340B ID
CAH141319-00
Entity Address
600 North College Ave
Geneseo, IL 61254-1099
Medicare Provider Number
141319
Participating Start Date
10/1/2012
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-4511
Pharmacy Address
1601 18TH STREET
SILVIS, IL 61282
Pharmacy Comments
Contract Details
Approval Date
7/10/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/11/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Laura J Domino, Vice President of Patient Care Services
(309) 944-9101
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
7/10/2018
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