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WALMART PHARMACY 10-5169
DSH260070 PEMISCOT COUNTY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
PEMISCOT COUNTY MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260070
Entity Address
946 East Reed
HAYTI, MO 63851
Medicare Provider Number
260070
Participating Start Date
1/1/2015
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-5169
Pharmacy Address
2252 NORTH 8TH STREET
SUITE A
ROGERS, AR 72756
Pharmacy Comments
Contract Details
Approval Date
1/9/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
DAVID KETCHUM, CEO
(573) 359-3579
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/9/2023
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