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WALMART PHARMACY 10-5169
RRC140043-00 CGH MEDICAL CENTER
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Covered Entity Details
Entity Name
CGH MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC140043-00
Entity Address
100 EAST LEFEVRE ROAD
STERLING, IL 61081-1278
Medicare Provider Number
140043
Participating Start Date
1/1/2023
Last Recertification Date
8/27/2024
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
7/7/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ben Schaab, VP, CFO
(815) 625-0400
Contract Pharmacy Representative
Walmart
Van Donn, 340B Director Contracting
(479) 273-4000
Signed By Date
7/7/2023
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