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WAL-MART PHARMACY 10-1307
DSH140155C Presence St. Mary's Hospital
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Covered Entity Details
Entity Name
Presence St. Mary's Hospital
Subdivision Name
Occupational Health Clinic
Type
Disproportionate Share Hospital
340B ID
DSH140155C
Entity Address
21 Heritage Drive
Bourbonnais, IL 60914
Medicare Provider Number
140155
Outpatient Facility Provider Number
Participating Start Date
10/1/2014
Last Recertification Date
9/4/2015
Entity Termination Date
1/1/2016
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1307
Pharmacy Address
2080 N. STATE ROUTE 50
BOURBONNAIS, IL 60914
Pharmacy Comments
Contract Details
Approval Date
9/17/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2016
Contacts
Covered Entity Signing Official
Amy Lafine, CEO/Chief Nursing Officer
(815) 937-2401
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
9/17/2014
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