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WAL-MART PHARMACY 10-1632
CAH241376-00 GLACIAL RIDGE HEALTH SYSTEM
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Covered Entity Details
Entity Name
GLACIAL RIDGE HEALTH SYSTEM
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241376-00
Entity Address
10 FOURTH AVE SE
GLENWOOD, MN 56334
Medicare Provider Number
241376
Participating Start Date
10/1/2011
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1632
Pharmacy Address
4611 HWY 29 SO
ALEXANDRIA, MN 56308
Pharmacy Comments
Contract Details
Approval Date
4/9/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
KYLE CHASE, CFO
(320) 634-2206
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/9/2019
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