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WALMART PHARMACY 10-5169
CAH141346-00 Sarah Bush Lincoln Fayette County Hospital
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Covered Entity Details
Entity Name
Sarah Bush Lincoln Fayette County Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH141346-00
Entity Address
650 W. Taylor Street
VANDALIA, IL 62471
Medicare Provider Number
141346
Participating Start Date
1/1/2023
Last Recertification Date
8/26/2024
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
Contacts
Covered Entity Signing Official
Karen Ann Dyer, CEO
(618) 283-5400
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
4/14/2023
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