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WAL-MART PHARMACY 10-0101
DSH260017 PHELPS COUNTY REGIONAL MEDICAL CNTR
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Covered Entity Details
Entity Name
PHELPS COUNTY REGIONAL MEDICAL CNTR
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260017
Entity Address
1000 WEST 10TH STREET
ROLLA, MO 65401
Medicare Provider Number
260017
Participating Start Date
3/2/2021
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0101
Pharmacy Address
500 S BISHOP
ROLLA, MO 65401
Pharmacy Comments
Contract Details
Approval Date
2/1/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
EDWARD J. CLAYTON, Chief Executive Officer
(573) 458-7919
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/15/2013
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