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WALMART PHARMACY 10-5169
SCH430012-00 AVERA SACRED HEART HOSPITAL
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Covered Entity Details
Entity Name
AVERA SACRED HEART HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH430012-00
Entity Address
501 SUMMIT ST
YANKTON, SD 57078
Medicare Provider Number
430012
Participating Start Date
4/21/2022
Last Recertification Date
8/28/2023
Entity Termination Date
1/1/2024
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
1/10/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Melissa Goff, Vice President - Pharmacy
(605) 322-8548
Contract Pharmacy Representative
Walmart
Kathi Phelps, Manager Contracting & Channel Management
(479) 277-3719
Signed By Date
1/10/2023
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