Contract Pharmacy Details

WAL-MART PHARMACY 10-0317
DSH140137 HSHS Holy Family Hospital, Inc.

Covered Entity Details

Entity Name

HSHS Holy Family Hospital, Inc.

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH140137

Entity Address

200 Healthcare Drive
Greenville, IL 62246

Medicare Provider Number

140137

Participating Start Date

7/1/2012

Last Recertification Date

8/27/2021

Entity Termination Date

4/1/2022

Pharmacy Details

Pharmacy Name

WAL-MART PHARMACY 10-0317

Pharmacy Address

201 NORTH MATTES AVE
VANDALIA, IL 62471

Pharmacy Comments

Contract Details

Approval Date

10/16/2014

Contract Begin Date

1/1/2015

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

1/24/2018
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Brian Nall, CEO
(618) 664-1230 Ext: 8410

Contract Pharmacy Representative

Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719

Signed By Date

10/16/2014

340B Drug Pricing Program Database