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WAL-MART PHARMACY 10-5274
RRC120026-00 PALI MOMI MEDICAL CENTER
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Covered Entity Details
Entity Name
PALI MOMI MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC120026-00
Entity Address
98-1079 MOANALUA ROAD
AIEA, HI 96701
Medicare Provider Number
120026
Participating Start Date
11/9/2020
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5274
Pharmacy Address
1131 KUALA ST.
PEARL CITY, HI 96782
Pharmacy Comments
Contract Details
Approval Date
11/9/2020
Contract Begin Date
11/9/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/24/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
MARTHA SMITH, Executive Vice President, Oahu Operations
(808) 522-2520
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/14/2020
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