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WAL-MART PHARMACY 10-0359
DSH040004 WASHINGTON REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
WASHINGTON REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH040004
Entity Address
3215 N. NORTH HILLS BLVD
FAYETTEVILLE, AR 72703
Medicare Provider Number
040004
Participating Start Date
7/1/2018
Last Recertification Date
9/10/2021
Entity Termination Date
1/1/2022
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0359
Pharmacy Address
3919 N. MALL AVE
FAYETTEVILLE, AR 72703
Pharmacy Comments
Contract Details
Approval Date
1/12/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Dan Ray Eckels, Sr VP & CFO
(479) 463-2825 Ext: 4794636026
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/12/2021
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