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WAL-MART PHARMACY 10-1454
CHC24098-00 SOUTHERN ILLINOIS UNIVERSITY
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Covered Entity Details
Entity Name
SOUTHERN ILLINOIS UNIVERSITY
Subdivision Name
SIU Center for Family Medicine
Type
HRSA-Funded Health Center
340B ID
CHC24098-00
Entity Address
520 N 4th St
Springfield, IL 62702-5238
Grant Number
H80CS24098
Participating Start Date
1/1/2013
Last Recertification Date
2/11/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1454
Pharmacy Address
5211 BROADWAY STREET
QUINCY, IL 62301
Pharmacy Comments
Contract Details
Approval Date
1/15/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Iris Elenora Wesley, CEO
(217) 757-8116
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
1/15/2018
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