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WALMART PHARMACY 10-5169
CAH141353-00 Iroquois Memorial Hospital
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Covered Entity Details
Entity Name
Iroquois Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH141353-00
Entity Address
200 E. Fairman Ave.
Watseka, IL 60970
Medicare Provider Number
141353
Participating Start Date
1/1/2024
Last Recertification Date
8/22/2024
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
11/14/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Shawn Bransky, Chief Financial Officer
(815) 432-7929
Contract Pharmacy Representative
Walmart
Julie Howard, 340b Program Manager
(479) 739-1973 Ext: 4792771498
Signed By Date
10/13/2023
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