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WAL-MART PHARMACY 10-0173
CAH261336-00 IRON COUNTY HOSPITAL
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Covered Entity Details
Entity Name
IRON COUNTY HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH261336-00
Entity Address
301 NORTH HWY 21
PILOT KNOB, MO 63663
Medicare Provider Number
261336
Participating Start Date
10/1/2016
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0173
Pharmacy Address
#1 MEMORIAL DR
POTOSI, MO 63664
Pharmacy Comments
Contract Details
Approval Date
1/15/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/15/2019
Agreement registered in error
Contacts
Covered Entity Signing Official
Joshua Gilmore, Chief Executive Officer
(573) 546-8003
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/15/2019
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