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WAL-MART PHARMACY 10-5997
CAH141331-01 MARSHALL BROWNING HOSPITAL ASSOCIATION
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Covered Entity Details
Entity Name
MARSHALL BROWNING HOSPITAL ASSOCIATION
Subdivision Name
MARSHALL BROWNING PHYSICIAN CLINIC
Type
Critical Access Hospital
340B ID
CAH141331-01
Entity Address
905 NORTH WASHINGTON STREET
DU QUOIN, IL 62832
Medicare Provider Number
141331
Outpatient Facility Provider Number
148504
Participating Start Date
1/1/2017
Last Recertification Date
8/16/2024
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
10/14/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Daniel Eaves, CEO
(618) 542-1042
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/14/2019
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