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WAL-MART PHARMACY 10-0020
DSH260175Q GOLDEN VALLEY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
GOLDEN VALLEY MEMORIAL HOSPITAL
Subdivision Name
CANCER CENTER - CLINTON - ONCOLOGY
Type
Disproportionate Share Hospital
340B ID
DSH260175Q
Entity Address
1600 NORTH SECOND STREET
CLINTON, MO 64735
Medicare Provider Number
260175
Outpatient Facility Provider Number
Participating Start Date
10/1/2021
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0020
Pharmacy Address
1712 EAST OHIO
CLINTON, MO 64735
Pharmacy Comments
Contract Details
Approval Date
1/4/2022
Contract Begin Date
1/14/2022
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
1/4/2022
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