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WAL-MART PHARMACY 10-0550
CAH141344-00 LAWRENCE COUNTY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
LAWRENCE COUNTY MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH141344-00
Entity Address
2200 STATE STREET
LAWRENCEVILLE, IL 62439
Medicare Provider Number
141344
Participating Start Date
1/1/2016
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0550
Pharmacy Address
2610 W. HAVEN RD.
LAWRENCEVILLE, IL 62439
Pharmacy Comments
Contract Details
Approval Date
4/1/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Doug Florkowski, CEO
(618) 943-7200
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
4/1/2016
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