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WAL-MART PHARMACY 10-5402
DSH140180 Presence Saints Mary and Elizabeth Medical Center
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Covered Entity Details
Entity Name
Presence Saints Mary and Elizabeth Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140180
Entity Address
2233 WEST DIVISION STREET
CHICAGO, IL 60622
Medicare Provider Number
140180
Participating Start Date
7/1/2003
Last Recertification Date
8/16/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5402
Pharmacy Address
4650 WEST NORTH AVE
CHICAGO, IL 60639
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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