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WAL-MART PHARMACY 10-5315
DSH140228 SWEDISH AMERICAN HOSPITAL
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Covered Entity Details
Entity Name
SWEDISH AMERICAN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140228
Entity Address
1401 E STATE ST
ROCKFORD, IL 61104
Medicare Provider Number
140228
Participating Start Date
9/9/2005
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
4/12/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/23/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Patricia A. DeWane, Vice President, Finance and Treasurer
(779) 696-4727
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
4/12/2019
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