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WAL-MART PHARMACY 10-5315
SCH140167-00 IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME
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Covered Entity Details
Entity Name
IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH140167-00
Entity Address
200 E FAIRMAN AVE
WATSEKA, IL 60970-1644
Medicare Provider Number
140167
Participating Start Date
4/1/2014
Last Recertification Date
8/28/2019
Entity Termination Date
10/1/2020
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
Contract Termination Date
Termination Reason
10/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jeff Petersen, VP
(815) 432-7720
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/15/2019
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