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WAL-MART PHARMACY 10-3400
DSH140174 PRESENCE MERCY MEDICAL CENTER
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Covered Entity Details
Entity Name
PRESENCE MERCY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140174
Entity Address
1325 NORTH HIGHLAND AVENUE, ATTN: ADMINISTRATION
AURORA, IL 60506
Medicare Provider Number
140174
Participating Start Date
4/1/2010
Last Recertification Date
8/16/2024
Entity Termination Date
4/1/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3400
Pharmacy Address
2300 ROUTE 34
OSWEGO, IL 60543
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
3/16/2017
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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