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WAL-MART PHARMACY 10-0197
SCH140089-00 MCDONOUGH DISTRICT HOSPITAL
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Covered Entity Details
Entity Name
MCDONOUGH DISTRICT HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH140089-00
Entity Address
525 E. GRANT
MACOMB, IL 61455
Medicare Provider Number
140089
Participating Start Date
7/1/2017
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0197
Pharmacy Address
1730 EAST JACKSON ROAD
MACOMB, IL 61455
Pharmacy Comments
Contract Details
Approval Date
10/10/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
William R Murdock, President & CEO
(309) 833-4101 Ext: 13499
Contract Pharmacy Representative
Walmart
Julie Howard, 340b Program Manager
(479) 739-1973 Ext: 4792771498
Signed By Date
10/10/2019
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