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WAL-MART PHARMACY 10-5485
RRC140179-00 OSF LITTLE COMPANY OF MARY MEDICAL CENTER
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Covered Entity Details
Entity Name
OSF LITTLE COMPANY OF MARY MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC140179-00
Entity Address
2800 WEST 95TH STREET
EVERGREEN PARK, IL 60805
Medicare Provider Number
140179
Participating Start Date
1/1/2019
Last Recertification Date
8/30/2021
Entity Termination Date
10/1/2021
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5485
Pharmacy Address
2500 W. 95TH ST.
EVERGREEN PARK, IL 60805
Pharmacy Comments
Contract Details
Approval Date
7/9/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Diane L. McGrew, President
(309) 655-2850
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
7/9/2021
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