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WAL-MART PHARMACY 10-0786
DSH140239 Javon Bea Hospital
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Covered Entity Details
Entity Name
Javon Bea Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140239
Entity Address
8201 E Riverside Blvd
Rockford, IL 61114
Medicare Provider Number
140239
Participating Start Date
1/1/2008
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0786
Pharmacy Address
2300 SYCAMORE ROAD
DEKALB, IL 60115
Pharmacy Comments
Contract Details
Approval Date
1/15/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/24/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Shannon Dunphy-Alexander, Senior Vice President / CFO
(608) 757-3126
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/15/2020
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