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WAL-MART PHARMACY 10-1071
DSH140052 OSF SAINT ANTHONY'S HEALTH CENTER
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Covered Entity Details
Entity Name
OSF SAINT ANTHONY'S HEALTH CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH140052
Entity Address
1 SAINT ANTHONYS WAY
ALTON, IL 62002
Medicare Provider Number
140052
Participating Start Date
3/15/2022
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1071
Pharmacy Address
610 WESLEY DRIVE
WOOD RIVER, IL 62095
Pharmacy Comments
Contract Details
Approval Date
7/12/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/8/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Diane L. McGrew, President
(309) 655-2850
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
7/12/2016
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