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WAL-MART PHARMACY 10-0481
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 10-0481
Pharmacy Address
101 DETTRO DRIVE
MATTOON, IL 61938
Pharmacy Comments
Contract Details
Approval Date
4/12/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Iris Elenora Wesley, CEO
(217) 757-8116
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
4/12/2018
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