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WALMART PHARMACY 10-5169
CAH141315-00 Illini Community Hospital
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Covered Entity Details
Entity Name
Illini Community Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH141315-00
Entity Address
640 W. Washington Street
Pittsfield, IL 62363
Medicare Provider Number
141315
Participating Start Date
1/1/2014
Last Recertification Date
8/12/2024
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
10/13/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Holly Jones, Administrator
(217) 285-2113
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
10/13/2023
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