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Walmart Pharmacy 10-7611
DSH140164 MEMORIAL HOSPITAL OF CARBONDALE
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Covered Entity Details
Entity Name
MEMORIAL HOSPITAL OF CARBONDALE
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140164
Entity Address
405 WEST JACKSON STREET
CARBONDALE, IL 62901
Medicare Provider Number
140164
Participating Start Date
1/1/2009
Last Recertification Date
9/10/2024
Pharmacy Details
Pharmacy Name
Walmart Pharmacy 10-7611
Pharmacy Address
2501 Perry Rd
Plainfield, IN 46168
Pharmacy Comments
Contract Details
Approval Date
1/12/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Warren Ladner, CFO
(618) 457-5200 Ext: 67130
Contract Pharmacy Representative
Verity
Keren Garcia, Account Manager
(425) 296-1056
Signed By Date
1/12/2024
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