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WAL-MART PHARMACY 10-3601
DSH140048 ADVOCATE SOUTHLAND HEALTH NETWORK
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Covered Entity Details
Entity Name
ADVOCATE SOUTHLAND HEALTH NETWORK
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140048
Entity Address
2320 E. 93RD ST.
CHICAGO, IL 60617
Medicare Provider Number
140048
Participating Start Date
10/1/2015
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3601
Pharmacy Address
4700 W. 135TH STREET
CRESTWOOD, IL 60418
Pharmacy Comments
Contract Details
Approval Date
10/8/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/13/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Maureen A. Morrison, Vice President, Finance
(773) 967-5050 Ext: 5050
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
10/8/2015
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