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WAL-MART PHARMACY 10-0453
DSH260160 SOUTHEASTHEALTH CENTER OF STODDARD CTY; dba MERCY HOSPITAL STODDARD
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Covered Entity Details
Entity Name
SOUTHEASTHEALTH CENTER OF STODDARD CTY; dba MERCY HOSPITAL STODDARD
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260160
Entity Address
1200 NORTH ONE MILE ROAD
DEXTER, MO 63841
Medicare Provider Number
260160
Participating Start Date
7/1/2019
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0453
Pharmacy Address
1007 N DOUGLAS
MALDEN, MO 63863
Pharmacy Comments
Contract Details
Approval Date
7/16/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Sue Ann Williams, CEO
(573) 614-1900
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
7/16/2019
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