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WAL-MART PHARMACY 10-0222
CAH141349-00 Sparta Community Hospital District
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Covered Entity Details
Entity Name
Sparta Community Hospital District
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH141349-00
Entity Address
818 East Broadway Street
Sparta, IL 62286
Medicare Provider Number
141349
Participating Start Date
1/1/2013
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0222
Pharmacy Address
1410 NORTH MARKET STREET
SPARTA, IL 62286
Pharmacy Comments
Contract Details
Approval Date
4/1/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Paul M. Mueller, CFO
(618) 443-2177 Ext: 1403
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
4/1/2015
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