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WAL-MART PHARMACY 10-1470
DSH240088 RICE MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
RICE MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH240088
Entity Address
301 BECKER AVE. SW
WILLMAR, MN 56201
Medicare Provider Number
240088
Participating Start Date
6/25/2018
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1470
Pharmacy Address
700 19TH AVE SE
WILLMAR, MN 56201
Pharmacy Comments
Contract Details
Approval Date
6/25/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/17/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Carnita Rae Allex, Administrator
(507) 637-4500 Ext: 47301
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
6/25/2018
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