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WAL-MART PHARMACY 10-0334
CAH141347-00 CARLINVILLE AREA HOSPITAL
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Covered Entity Details
Entity Name
CARLINVILLE AREA HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH141347-00
Entity Address
20733 NORTH BROAD STREET
CARLINVILLE, IL 62626
Medicare Provider Number
141347
Participating Start Date
7/1/2017
Last Recertification Date
9/17/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0334
Pharmacy Address
18600 SHIPMAN BLACK TOP ROAD
CARLINVILLE, IL 62626
Pharmacy Comments
Contract Details
Approval Date
4/18/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/28/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Michael J. Brown, Chief Financial Officer
(217) 854-3857
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
4/18/2017
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