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WAL-MART PHARMACY 10-1740
DSH140239 Javon Bea Hospital
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Covered Entity Details
Entity Name
Javon Bea Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140239
Entity Address
8201 E Riverside Blvd
Rockford, IL 61114
Medicare Provider Number
140239
Participating Start Date
1/1/2008
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1740
Pharmacy Address
2545 ILLINOS ROUTE 26 SOUTH RD
FREEPORT, IL 61032
Pharmacy Comments
Contract Details
Approval Date
7/10/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/27/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Henry Seybold, Senior Vice President / CFO
(815) 971-6796
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
7/10/2015
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