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WAL-MART PHARMACY 10-2608
CAH271309-00 PRAIRIE COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
PRAIRIE COMMUNITY HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH271309-00
Entity Address
312 S. ADAMS AVE
TERRY, MT 59349-0156
Medicare Provider Number
271309
Participating Start Date
4/1/2021
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2608
Pharmacy Address
3205 STOWER STREET
MILES CITY, MT 59301
Pharmacy Comments
Contract Details
Approval Date
4/12/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Burt Keltner, CEO
(406) 635-5511 Ext: 12
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/12/2021
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