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WAL-MART PHARMACY 10-1307
DSH140155A Presence St. Mary's Hospital
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Covered Entity Details
Entity Name
Presence St. Mary's Hospital
Subdivision Name
MedCentre Imaging
Type
Disproportionate Share Hospital
340B ID
DSH140155A
Entity Address
555 W Court St
Kankakee, IL 60901
Medicare Provider Number
140155
Outpatient Facility Provider Number
Participating Start Date
10/1/2014
Last Recertification Date
Entity Termination Date
7/1/2015
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
7/1/2015
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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