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WAL-MART PHARMACY 10-0253
CAH141300-00 THOMAS H BOYD CRITICAL ACC HOSPITAL
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Covered Entity Details
Entity Name
THOMAS H BOYD CRITICAL ACC HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH141300-00
Entity Address
800 SCHOOL STREET
CARROLLTON, IL 62016
Medicare Provider Number
141300
Participating Start Date
10/1/2018
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0253
Pharmacy Address
1316 SOUTH STATE STREET
JERSEYVILLE, IL 62052
Pharmacy Comments
Contract Details
Approval Date
4/4/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Deborah J Campbell, CEO
(217) 942-6946
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
4/4/2019
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