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WAL-MART PHARMACY 10-0481
CHC24098-05 SOUTHERN ILLINOIS UNIVERSITY
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Covered Entity Details
Entity Name
SOUTHERN ILLINOIS UNIVERSITY
Subdivision Name
SIU Center for Family Medicine-Decatur
Type
HRSA-Funded Health Center
340B ID
CHC24098-05
Entity Address
102 West Kenwood Avenue
Decatur, IL 62526
Grant Number
H80CS24098
Participating Start Date
1/1/2018
Last Recertification Date
2/11/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0481
Pharmacy Address
101 DETTRO DRIVE
MATTOON, IL 61938
Pharmacy Comments
Contract Details
Approval Date
7/15/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Iris Elenora Wesley, CEO
(217) 757-8116
Contract Pharmacy Representative
SIU Center for Family Medicine
Michael Black, CFO
(217) 747-6470
Signed By Date
7/15/2024
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