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WAL-MART PHARMACY 10-5485
DSH140018 MOUNT SINAI HOSPITAL MEDICAL CENTER
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Covered Entity Details
Entity Name
MOUNT SINAI HOSPITAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140018
Entity Address
2750 W 15TH PLACE
CHICAGO, IL 60608-1797
Medicare Provider Number
140018
Participating Start Date
10/1/2004
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5485
Pharmacy Address
2500 W. 95TH ST.
EVERGREEN PARK, IL 60805
Pharmacy Comments
Contract Details
Approval Date
1/8/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/19/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
CHARLES WEIS, EXECUTIVE VP & CFO
(773) 257-6642
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/8/2014
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