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WAL-MART PHARMACY 10-3837
DSH140228 SWEDISH AMERICAN HOSPITAL
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Covered Entity Details
Entity Name
SWEDISH AMERICAN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140228
Entity Address
1401 E STATE ST
ROCKFORD, IL 61104
Medicare Provider Number
140228
Participating Start Date
9/9/2005
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3837
Pharmacy Address
4781 EAST ROCKTON RD.
ROSCOE, IL 61073
Pharmacy Comments
Contract Details
Approval Date
4/9/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/23/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Patricia A. DeWane, Vice President, Finance and Treasurer
(779) 696-4727
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/9/2020
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