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WAL-MART PHARMACY 10-0363
CAH261332-00 Carroll County Memorial Hospital
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Covered Entity Details
Entity Name
Carroll County Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH261332-00
Entity Address
1502 N Jefferson
Carrollton, MO 64633
Medicare Provider Number
261332
Participating Start Date
4/1/2013
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0363
Pharmacy Address
855 S. CHEROKEE DR.
MARSHALL, MO 65340
Pharmacy Comments
Contract Details
Approval Date
1/4/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tim Braun, Chief Operating Officer
(660) 542-1695 Ext: 3067
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/4/2019
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