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WAL-MART PHARMACY 10-3065
DSH140080 PRESENCE SAINT FRANCIS HOSPITAL
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Covered Entity Details
Entity Name
PRESENCE SAINT FRANCIS HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140080
Entity Address
355 RIDGE AVE.
EVANSTON, IL 60202
Medicare Provider Number
140080
Participating Start Date
7/1/2007
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3065
Pharmacy Address
3636 N BROADWAY
CHICAGO, IL 60613
Pharmacy Comments
Contract Details
Approval Date
9/14/2012
Contract Begin Date
9/14/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
John A. Orsini, Executive Vice President and Chief Financial Officer
(847) 813-3707
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
8/28/2012
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