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WAL-MART PHARMACY 10-0801
DSH260006 HEARTLAND REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
HEARTLAND REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260006
Entity Address
5325 FARAON
ST. JOSEPH, MO 64506-3398
Medicare Provider Number
260006
Participating Start Date
1/1/2024
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0801
Pharmacy Address
1605 SOUTH MAIN STREET
MARYVILLE, MO 64468
Pharmacy Comments
Contract Details
Approval Date
4/14/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Dwain Stilson, Chief Financial Officer
(816) 271-7070
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
4/13/2020
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