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WALMART PHARMACY 10-5169
CAH361323-00 Aultman Orrville Hospital
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Covered Entity Details
Entity Name
Aultman Orrville Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH361323-00
Entity Address
832 SOUTH MAIN STREET
ORRVILLE, OH 44667
Medicare Provider Number
361323
Participating Start Date
1/1/2011
Last Recertification Date
8/26/2024
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
1/12/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/21/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Tyler Lee Immel, Executive Director of Finance
(330) 363-4790
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
1/12/2023
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