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WAL-MART PHARMACY 10-4511
DSH140275 GENESIS MEDICAL CENTER - SILVIS
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Covered Entity Details
Entity Name
GENESIS MEDICAL CENTER - SILVIS
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140275
Entity Address
801 Illini Drive
Silvis, IL 61282
Medicare Provider Number
140275
Participating Start Date
1/1/2019
Last Recertification Date
8/14/2023
Entity Termination Date
1/1/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-4511
Pharmacy Address
1601 18TH STREET
SILVIS, IL 61282
Pharmacy Comments
Contract Details
Approval Date
1/14/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/15/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Mark Rogers, CFO
(563) 421-6513
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/14/2019
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