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WALMART PHARMACY 10-5169
DSH140228 SWEDISH AMERICAN HOSPITAL
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Covered Entity Details
Entity Name
SWEDISH AMERICAN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140228
Entity Address
1401 E STATE ST
ROCKFORD, IL 61104
Medicare Provider Number
140228
Participating Start Date
9/9/2005
Last Recertification Date
8/28/2024
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
4/10/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/23/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Patricia Ann DeWane, Vice President, Finance and Treasurer
(779) 696-4009
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/10/2023
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