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WAL-MART PHARMACY 10-1028
SCH140001-00 GRAHAM HOSPITAL ASSOCIATION
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Covered Entity Details
Entity Name
GRAHAM HOSPITAL ASSOCIATION
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH140001-00
Entity Address
210 W. Walnut Street
Canton, IL 61520
Medicare Provider Number
140001
Participating Start Date
7/1/2015
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1028
Pharmacy Address
401 RIVER ROAD
EAST PEORIA, IL 61611
Pharmacy Comments
Contract Details
Approval Date
1/12/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/10/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Holly Henline, VP of Ancillary Services & Corporate Compliance Officer
(309) 647-5240 Ext: 2709
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/12/2023
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