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Walmart Pharmacy 10-7611
CAH141317-00 GIBSON COMMUNITY HOSPITAL DBA GIBSON AREA HOSPITAL AND HEALTH SERVICES
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Covered Entity Details
Entity Name
GIBSON COMMUNITY HOSPITAL DBA GIBSON AREA HOSPITAL AND HEALTH SERVICES
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH141317-00
Entity Address
1120 N MELVIN
GIBSON CITY, IL 60936
Medicare Provider Number
141317
Participating Start Date
7/1/2011
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
Walmart Pharmacy 10-7611
Pharmacy Address
2501 Perry Rd
Plainfield, IN 46168
Pharmacy Comments
Contract Details
Approval Date
10/6/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Matthew Ertel, CFO
(217) 784-2601
Contract Pharmacy Representative
WALMART
Van Donn, Director, 340B Contracting
(479) 277-1498
Signed By Date
10/6/2023
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