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WAL-MART PHARMACY 10-3255
DSH140091 The Carle Foundation Hospital
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Covered Entity Details
Entity Name
The Carle Foundation Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140091
Entity Address
611 West Park Street
Urbana, IL 61801
Medicare Provider Number
140091
Participating Start Date
10/1/2012
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3255
Pharmacy Address
505 S. DUNLAP AVENUE
SAVOY, IL 61874
Pharmacy Comments
Contract Details
Approval Date
4/15/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Dennis P. Hesch, Executive VP and CFO
(217) 326-8231
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
4/15/2015
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