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WALMART PHARMACY 10-5169
CAH141319-00 Henry District Hospital
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Covered Entity Details
Entity Name
Henry District Hospital
Subdivision Name
Hammond Henry Hospital
Type
Critical Access Hospital
340B ID
CAH141319-00
Entity Address
600 North College Ave
Geneseo, IL 61254-1099
Medicare Provider Number
141319
Participating Start Date
10/1/2012
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-5169
Pharmacy Address
2252 NORTH 8TH STREET
SUITE A
ROGERS, AR 72756
Pharmacy Comments
Contract Details
Approval Date
1/16/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Wyatt Stanley Brieser, Director of Ancillary and Outpatient Services
(309) 944-9233
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/16/2023
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