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WAL-MART PHARMACY 10-4246
DSH240101 ST MARYS REGIONAL HEALTH CENTER
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Covered Entity Details
Entity Name
ST MARYS REGIONAL HEALTH CENTER
Subdivision Name
Essentia Health St. Mary's
Type
Disproportionate Share Hospital
340B ID
DSH240101
Entity Address
1027 WASHINGTON AVE
DETROIT LAKES, MN 56501
Medicare Provider Number
240101
Participating Start Date
1/1/2015
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-4246
Pharmacy Address
100 JUNIPER AVENUE NW
WADENA, MN 56482
Pharmacy Comments
Contract Details
Approval Date
10/19/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Tanner Goodrich, Senior Vice President of Operations
(218) 847-0851
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/19/2022
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