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Walmart Pharmacy 10-7611
CAH141338-00 Memorial Hospital
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Covered Entity Details
Entity Name
Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH141338-00
Entity Address
1900 State Street
Chester, IL 62233
Medicare Provider Number
141338
Participating Start Date
4/1/2012
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
Walmart Pharmacy 10-7611
Pharmacy Address
2501 Perry Rd
Plainfield, IN 46168
Pharmacy Comments
Contract Details
Approval Date
10/9/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brett Bollmann, Chief Executive Officer
(618) 826-4581 Ext: 1298
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/9/2023
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