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WAL-MART PHARMACY 10-0454
DSH140046 SSM HEALTH GOOD SAMARITAN HOSPITAL
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Covered Entity Details
Entity Name
SSM HEALTH GOOD SAMARITAN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140046
Entity Address
1 GOOD SAMARITAN WAY
MT. VERNON, IL 62864
Medicare Provider Number
140046
Participating Start Date
7/1/2023
Last Recertification Date
8/15/2024
Entity Termination Date
7/1/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0454
Pharmacy Address
150 COMMERCE DR.
FAIRFIELD, IL 62837
Pharmacy Comments
Contract Details
Approval Date
6/5/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Eileen Lamm, Regional Vice President-Finance
(314) 994-6219
Contract Pharmacy Representative
Walmart
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
4/17/2023
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