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WAL-MART PHARMACY 10-0633
CAH141325-00 OSF Saint Luke Medical Center
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Covered Entity Details
Entity Name
OSF Saint Luke Medical Center
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH141325-00
Entity Address
1051 WEST SOUTH STREET
KEWANEE, IL 61443
Medicare Provider Number
141325
Participating Start Date
1/1/2011
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0633
Pharmacy Address
730 TENNEY STREET
KEWANEE, IL 61443
Pharmacy Comments
Contract Details
Approval Date
1/10/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/28/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Lynn A. Fulton, CEO
(309) 852-7521
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/10/2014
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