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WAL-MART PHARMACY 10-2100
SCH230133-00 MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH230133-00
Entity Address
825 N. CENTER AVENUE
GAYLORD, MI 49735
Medicare Provider Number
230133
Participating Start Date
8/11/2010
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2100
Pharmacy Address
1150 SOUTH MAIN
CHEBOYGAN, MI 49721
Pharmacy Comments
Contract Details
Approval Date
1/18/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/1/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Alicia Maitland, CFO
(231) 935-7840
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
1/18/2022
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