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WALMART PHARMACY 10-5169
CHC24098-19 SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF MEDICINE
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Covered Entity Details
Entity Name
SOUTHERN ILLINOIS UNIVERSITY SCHOOL OF MEDICINE
Subdivision Name
SIU Center for Family Medicine - General Internal Medicine Clinic
Type
HRSA-Funded Health Center
340B ID
CHC24098-19
Entity Address
751 N Rutledge St Ste 1100
Springfield, IL 62702-4968
Grant Number
H80CS24098
Participating Start Date
10/1/2024
Last Recertification Date
2/11/2025
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
1/15/2025
Contract Begin Date
4/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Iris Elenora Wesley, CEO
(217) 757-8116
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
1/15/2025
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