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WALMART PHARMACY 10-5169
DSH140012 OSF Saint Katharine Medical Center
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Covered Entity Details
Entity Name
OSF Saint Katharine Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140012
Entity Address
403 EAST FIRST STREET
DIXON, IL 61021
Medicare Provider Number
140012
Participating Start Date
7/1/2024
Last Recertification Date
8/29/2024
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
5/1/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Austin B Frazier Jr., CFO
(815) 285-5513
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/15/2024
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