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WAL-MART PHARMACY 10-2607
DSH270051 KALISPELL REGIONAL MEDICAL CENTER d/b/a LOGAN HEALTH MEDICAL CENTER
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Covered Entity Details
Entity Name
KALISPELL REGIONAL MEDICAL CENTER d/b/a LOGAN HEALTH MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH270051
Entity Address
310 SUNNYVIEW LANE
KALISPELL, MT 59901
Medicare Provider Number
270051
Participating Start Date
1/1/2021
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2607
Pharmacy Address
36318 MEMORY LANE
POLSON, MT 59860
Pharmacy Comments
Contract Details
Approval Date
11/3/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Craig O Boyer, Chief Financial Officer
(406) 752-5111
Contract Pharmacy Representative
Walmart
Jodi Prohofsky, Sr. Director
(479) 277-1498
Signed By Date
10/9/2020
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