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WAL-MART PHARMACY 10-0796
CAH141310-00 Mendota Community Hospital d/b/a OSF Saint Paul Medical Center
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Covered Entity Details
Entity Name
Mendota Community Hospital d/b/a OSF Saint Paul Medical Center
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH141310-00
Entity Address
1401 E. 12th St.
MENDOTA, IL 61342
Medicare Provider Number
141310
Participating Start Date
1/1/2011
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0796
Pharmacy Address
5307 RT. 251
PERU, IL 61354
Pharmacy Comments
Contract Details
Approval Date
7/12/2016
Contract Begin Date
10/1/2016
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
Diane L. McGrew, President
(309) 655-2850
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
7/12/2016
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