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WAL-MART PHARMACY 10-5115
DSH160033 GENESIS MEDICAL CENTER - DAVENPORT
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Covered Entity Details
Entity Name
GENESIS MEDICAL CENTER - DAVENPORT
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH160033
Entity Address
1227 EAST RUSHOLME
DAVENPORT, IA 52803
Medicare Provider Number
160033
Participating Start Date
1/1/2019
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5115
Pharmacy Address
3101 W KIMBERLY RD
DAVENPORT (W), IA 52806
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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