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WAL-MART PHARMACY 10-1307
DSH140186 RIVERSIDE MEDICAL CENTER
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Covered Entity Details
Entity Name
RIVERSIDE MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140186
Entity Address
350 N Wall Street
KANKAKEE, IL 60901
Medicare Provider Number
140186
Participating Start Date
1/1/2007
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1307
Pharmacy Address
2080 N. STATE ROUTE 50
BOURBONNAIS, IL 60914
Pharmacy Comments
Contract Details
Approval Date
7/8/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/15/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Patricia K. Vilt, Vice President of Finance
(815) 935-7256
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
7/8/2014
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