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WALMART PHARMACY 10-5169
RRC140127-00 CARLE BROMENN MEDICAL CENTER
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Covered Entity Details
Entity Name
CARLE BROMENN MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC140127-00
Entity Address
1304 VIRGINIA
NORMAL, IL 61761
Medicare Provider Number
140127
Participating Start Date
2/17/2021
Last Recertification Date
9/4/2024
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
10/16/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Dennis P. Hesch, Executive VP and CFO
(217) 326-8231
Contract Pharmacy Representative
Walmart
Tisha Campbell, Director of Contracting
(949) 872-4138
Signed By Date
10/16/2023
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