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WAL-MART PHARMACY 10-1548
SCH140167-00 IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME
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Covered Entity Details
Entity Name
IROQUOIS MEMORIAL HOSPITAL AND RESIDENT HOME
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH140167-00
Entity Address
200 E FAIRMAN AVE
WATSEKA, IL 60970-1644
Medicare Provider Number
140167
Participating Start Date
4/1/2014
Last Recertification Date
8/28/2019
Entity Termination Date
10/1/2020
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1548
Pharmacy Address
1790 EAST WALNUT STREET
WATSEKA, IL 60970
Pharmacy Comments
Contract Details
Approval Date
10/1/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
LORI YELENICK, INTERIM CFO
(815) 432-7929
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
10/1/2014
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