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WAL-MART PHARMACY 10-5315
DSH140133 HOLY CROSS HOSPITAL
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Covered Entity Details
Entity Name
HOLY CROSS HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140133
Entity Address
2701 WEST 68TH STREET
CHICAGO, IL 60629
Medicare Provider Number
140133
Participating Start Date
7/1/2005
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
10/15/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Lori Pacura, President of Acute Care Hospitals
(773) 257-2914
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
10/15/2019
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