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WAL-MART PHARMACY 10-0596
DSH140164 MEMORIAL HOSPITAL OF CARBONDALE
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Covered Entity Details
Entity Name
MEMORIAL HOSPITAL OF CARBONDALE
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140164
Entity Address
405 WEST JACKSON STREET
CARBONDALE, IL 62901
Medicare Provider Number
140164
Participating Start Date
1/1/2009
Last Recertification Date
9/10/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0596
Pharmacy Address
1713 S. PARK AVE.
HERRIN, IL 62948
Pharmacy Comments
Contract Details
Approval Date
4/14/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
REX BUDDE, CEO
(618) 457-5200
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
4/14/2022
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