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WALMART PHARMACY 10-5169
CAH141349-00 Sparta Community Hospital District
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Covered Entity Details
Entity Name
Sparta Community Hospital District
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH141349-00
Entity Address
818 East Broadway Street
Sparta, IL 62286
Medicare Provider Number
141349
Participating Start Date
1/1/2013
Last Recertification Date
8/23/2024
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
7/3/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Lisa A Ernsting, CFO
(618) 443-2177 Ext: 1403
Contract Pharmacy Representative
Sparta Community Hospital
Quenci Howell, Director of Pharmacy
(618) 443-1394
Signed By Date
7/3/2023
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