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WAL-MART PHARMACY 10-5997
CAH141304-00 Genesis Medical Center, Aledo
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Covered Entity Details
Entity Name
Genesis Medical Center, Aledo
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH141304-00
Entity Address
409 NW 9TH AVE
ALEDO, IL 61231
Medicare Provider Number
141304
Participating Start Date
9/28/2010
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5997
Pharmacy Address
9600 PARKSOUTH CT. SUITE 100
ORLANDO, FL 32837
Pharmacy Comments
Contract Details
Approval Date
4/9/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Edward Rogalski, Administrator
(309) 582-3700
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/9/2019
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