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WALMART PHARMACY 10-5169
DSH140186 RIVERSIDE MEDICAL CENTER
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Covered Entity Details
Entity Name
RIVERSIDE MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140186
Entity Address
350 N Wall Street
KANKAKEE, IL 60901
Medicare Provider Number
140186
Participating Start Date
1/1/2007
Last Recertification Date
8/16/2024
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
4/7/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/15/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Patricia K. Vilt, Chief Financial Officer
(815) 935-7542 Ext: 37219
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
4/7/2023
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