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WALMART PHARMACY 10-5169
SCH140189-00 SARAH BUSH LINCOLN HEALTH CENTER
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Covered Entity Details
Entity Name
SARAH BUSH LINCOLN HEALTH CENTER
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH140189-00
Entity Address
1000 HEALTH CENTER DRIVE
MATTOON, IL 61938
Medicare Provider Number
140189
Participating Start Date
7/1/2018
Last Recertification Date
9/4/2024
Entity Termination Date
4/1/2025
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
4/17/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Bob O'Rourke, Chief Accounting Officer
(217) 258-2591
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/17/2023
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