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WAL-MART PHARMACY 10-0059
CAH261331-00 FREEMAN NEOSHO HOSPITAL
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Covered Entity Details
Entity Name
FREEMAN NEOSHO HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH261331-00
Entity Address
113 W. HICKORY STREET
NEOSHO, MO 64850
Medicare Provider Number
261331
Participating Start Date
9/20/2010
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0059
Pharmacy Address
1501 RANGELINE RD
JOPLIN, MO 64804
Pharmacy Comments
Contract Details
Approval Date
1/3/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
STEVE GRADDY, CFO
(417) 347-6678
Contract Pharmacy Representative
Wal-Mart
Jodi Prohofsky, Sr. Director, Payer Relations
(254) 301-6601
Signed By Date
1/3/2019
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