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WAL-MART PHARMACY 10-2714
CAH161300-00 BAUM HARMON MERCY HOSPITAL DBA MERCYONE PRIMGHAR MEDICAL CENTER
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Covered Entity Details
Entity Name
BAUM HARMON MERCY HOSPITAL DBA MERCYONE PRIMGHAR MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161300-00
Entity Address
255 NORTH WELCH AVENUE
PRIMGHAR, IA 51245
Medicare Provider Number
161300
Participating Start Date
1/1/2011
Last Recertification Date
9/4/2024
Entity Termination Date
10/1/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2714
Pharmacy Address
500 11TH STREET, S.W.
SPENCER, IA 51301
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
10/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Jesica Hanson, VP of Finance
(712) 279-5850
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
4/14/2021
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