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WALMART PHARMACY 10-5169
DSH140083 LORETTO HOSPITAL
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Covered Entity Details
Entity Name
LORETTO HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140083
Entity Address
645 SOUTH CENTRAL
CHICAGO, IL 60644
Medicare Provider Number
140083
Participating Start Date
12/6/2005
Last Recertification Date
8/29/2024
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
4/26/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/14/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
John Morales, Interim CFO
(773) 854-5438
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/26/2023
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