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WAL-MART PHARMACY 10-0250
DSH260175 GOLDEN VALLEY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
GOLDEN VALLEY MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260175
Entity Address
1600 NORTH SECOND
CLINTON, MO 64735-1192
Medicare Provider Number
260175
Participating Start Date
10/1/2021
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0250
Pharmacy Address
103 W POLK ST
WARSAW, MO 65355
Pharmacy Comments
Contract Details
Approval Date
8/9/2021
Contract Begin Date
10/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tammy Nadler, CFO
(660) 890-7105
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
7/15/2021
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