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WAL-MART PHARMACY 10-5315
SCH370022-00 JACKSON COUNTY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
JACKSON COUNTY MEMORIAL HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH370022-00
Entity Address
1200 EAST PECAN
ALTUS, OK 73521
Medicare Provider Number
370022
Participating Start Date
9/27/2010
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
1/14/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/5/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Shelley Simmons, VP of Patient Care
(580) 379-5533
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/14/2020
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