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WAL-MART PHARMACY 10-0028
DSH260137 FREEMAN HEALTH SYSTEM
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Covered Entity Details
Entity Name
FREEMAN HEALTH SYSTEM
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260137
Entity Address
1102 WEST 32ND STREET
JOPLIN, MO 64804-3503
Medicare Provider Number
260137
Participating Start Date
4/1/2004
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0028
Pharmacy Address
2415 N.W MAIN STREET
MIAMI, OK 74354
Pharmacy Comments
Contract Details
Approval Date
1/3/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2019
Agreement registered in error
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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