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WAL-MART PHARMACY 10-5315
CAH161377-01 MercyOne Centerville Medical Center
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Covered Entity Details
Entity Name
MercyOne Centerville Medical Center
Subdivision Name
MERCY RURAL HEALTH CLINIC DBA MercyOne Centerville Medical Clinic
Type
Critical Access Hospital
340B ID
CAH161377-01
Entity Address
19942 ST. JOSEPH'S DRIVE
CENTERVILLE, IA 52544
Medicare Provider Number
161377
Outpatient Facility Provider Number
168533
Participating Start Date
7/1/2011
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
7/15/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
ANN E YOUNG, INTERIM PRESIDENT
(641) 437-3434
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
7/15/2019
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