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WAL-MART PHARMACY 10-5315
RRC030119-00 MERCY GILBERT MEDICAL CENTER
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Covered Entity Details
Entity Name
MERCY GILBERT MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC030119-00
Entity Address
3555 S. VAL VISTA DRIVE
GILBERT, AZ 85297
Medicare Provider Number
030119
Participating Start Date
4/1/2018
Last Recertification Date
8/24/2023
Entity Termination Date
4/1/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
10/4/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/31/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Eric Sorensen, CFO
(480) 728-3144 Ext: 4807283144
Contract Pharmacy Representative
Walmart
Julie Howard, 340b Program Manager
(479) 739-1973 Ext: 4792771498
Signed By Date
10/4/2019
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