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WALMART PHARMACY 10-5169
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
WALMART PHARMACY 10-5169
Pharmacy Address
2252 NORTH 8TH STREET
SUITE A
ROGERS, AR 72756
Pharmacy Comments
Contract Details
Approval Date
4/14/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Warren Ladner, CFO
(618) 457-5200 Ext: 67130
Contract Pharmacy Representative
Walgreens
Debra Fogg, Client Relationship Analyst
(224) 300-5128
Signed By Date
4/14/2023
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