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WALMART PHARMACY 10-5169
CAH141302-00 Midwest Medical Center
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Covered Entity Details
Entity Name
Midwest Medical Center
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH141302-00
Entity Address
One Medical Center Drive
Galena, IL 61036
Medicare Provider Number
141302
Participating Start Date
1/1/2014
Last Recertification Date
8/20/2024
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
7/26/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tracy Bauer, CEO
(815) 776-7266
Contract Pharmacy Representative
Midwest Medical Center
Kelli Marie Jackson, Controller
(815) 776-7277
Signed By Date
7/26/2023
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