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WAL-MART PHARMACY 10-1485
SCH530002-00 CAMPBELL COUNTY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
CAMPBELL COUNTY MEMORIAL HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH530002-00
Entity Address
501 S BURMA AVENUE
GILLETTE, WY 82717-3011
Medicare Provider Number
530002
Participating Start Date
3/15/2022
Last Recertification Date
9/26/2023
Entity Termination Date
4/1/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1485
Pharmacy Address
2300 SOUTH DOUGLAS HIGHWAY
GILLETTE, WY 82718
Pharmacy Comments
Contract Details
Approval Date
7/5/2018
Contract Begin Date
3/15/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Dalton Huber, Chief Financial Officer
(307) 688-1523
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
7/5/2018
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