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WAL-MART PHARMACY 10-1375
CAH101304-00 CALHOUN-LIBERTY HOSPITAL
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Covered Entity Details
Entity Name
CALHOUN-LIBERTY HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH101304-00
Entity Address
20370 NE BURNS AVENUE
BLOUNTSTOWN, FL 32424
Medicare Provider Number
101304
Participating Start Date
8/10/2010
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1375
Pharmacy Address
2255 HIGHWAY 71
MARIANNA, FL 32448
Pharmacy Comments
Contract Details
Approval Date
4/14/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/22/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Christinia I Jepsen, CEO
(402) 686-4095
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
4/14/2021
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