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WAL-MART PHARMACY 10-3245
CAH521329-00 ST MARYS HOSPITAL OF SUPERIOR
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Covered Entity Details
Entity Name
ST MARYS HOSPITAL OF SUPERIOR
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521329-00
Entity Address
3500 TOWER AVE
SUPERIOR, WI 54880
Medicare Provider Number
521329
Participating Start Date
9/30/2010
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3245
Pharmacy Address
15594 STATE HIGHWAY 77
HAYWARD, WI 54843
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
Kim Pearson, Administrator
(715) 817-7017
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/19/2022
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