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WAL-MART PHARMACY 10-5315
CAH521322-01 GRANT REGIONAL HEALTH CENTER INC.
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Covered Entity Details
Entity Name
GRANT REGIONAL HEALTH CENTER INC.
Subdivision Name
GRANT REGIONAL COMMUNITY CLINIC - Family Medicine with Multi Specialty Clinic practice
Type
Critical Access Hospital
340B ID
CAH521322-01
Entity Address
507S MONROE ST
LANCASTER, WI 53813-2054
Medicare Provider Number
521322
Outpatient Facility Provider Number
528572
Participating Start Date
1/1/2018
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
1/14/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/14/2021
Agreement registered in error
Contacts
Covered Entity Signing Official
Tami Chambers, CCO
(608) 723-3234
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
1/14/2021
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