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Walmart Pharmacy 10-7611
CAH141319-00 Henry District Hospital
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Covered Entity Details
Entity Name
Henry District Hospital
Subdivision Name
Hammond Henry Hospital
Type
Critical Access Hospital
340B ID
CAH141319-00
Entity Address
600 North College Ave
Geneseo, IL 61254-1099
Medicare Provider Number
141319
Participating Start Date
10/1/2012
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
10/12/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Wyatt Stanley Brieser, Director of Ancillary and Outpatient Services
(309) 944-9233
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/12/2023
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