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WAL-MART PHARMACY 10-5402
DSH140182 ADVOCATE NORTH SIDE HEALTH NETWORK
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Covered Entity Details
Entity Name
ADVOCATE NORTH SIDE HEALTH NETWORK
Subdivision Name
DBA ADVOCATE ILLINOIS MASONIC MEDICAL CENTER (AIMMC)
Type
Disproportionate Share Hospital
340B ID
DSH140182
Entity Address
836 West Wellington Ave.
CHICAGO, IL 60657
Medicare Provider Number
140182
Participating Start Date
10/27/2005
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5402
Pharmacy Address
4650 WEST NORTH AVE
CHICAGO, IL 60639
Pharmacy Comments
Contract Details
Approval Date
10/14/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/10/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
JACK GILBERT, VP FINANCE
(773) 296-7809
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
10/14/2015
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