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WAL-MART PHARMACY 10-1418
RRC140046-00 GOOD SAMARITAN REGIONAL HEALTH CTR.
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Covered Entity Details
Entity Name
GOOD SAMARITAN REGIONAL HEALTH CTR.
Subdivision Name
Type
Rural Referral Center
340B ID
RRC140046-00
Entity Address
1 GOOD SAMARITAN WAY
MT. VERNON, IL 62864
Medicare Provider Number
140046
Participating Start Date
10/1/2015
Last Recertification Date
9/14/2022
Entity Termination Date
7/1/2023
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1418
Pharmacy Address
1530 WEST HWY 50
O'FALLON, IL 62269
Pharmacy Comments
Contract Details
Approval Date
4/14/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Kerry Swanson, Regional President
(618) 436-6500
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
4/14/2018
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