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WAL-MART PHARMACY 10-0820
DSH260142B JOHN FITZGIBBON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
JOHN FITZGIBBON MEMORIAL HOSPITAL
Subdivision Name
Grand River Medical Clinic
Type
Disproportionate Share Hospital
340B ID
DSH260142B
Entity Address
815 E. Broadway
Brunswick, MO 65236
Medicare Provider Number
260142
Outpatient Facility Provider Number
Participating Start Date
1/1/2020
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0820
Pharmacy Address
2150 MAIN ST
BOONVILLE, MO 65233
Pharmacy Comments
Contract Details
Approval Date
1/11/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Angy P. Littrell, President & CEO
(660) 831-3251
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
1/11/2023
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