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WAL-MART PHARMACY 10-0262
SCH140210-00 HARRISBURG MEDICAL CENTER INC.
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Covered Entity Details
Entity Name
HARRISBURG MEDICAL CENTER INC.
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH140210-00
Entity Address
100 DR WARREN TUTTLE DRIVE
HARRISBURG, IL 62946
Medicare Provider Number
140210
Participating Start Date
1/1/2025
Last Recertification Date
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0262
Pharmacy Address
919 GIACONE DR
BENTON, IL 62812
Pharmacy Comments
Contract Details
Approval Date
7/11/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
June Hayes, CFO
(618) 253-0141
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
7/11/2017
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