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WALMART PHARMACY 10-5169
CAH511313-00 BOONE MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
BOONE MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH511313-00
Entity Address
701 Madison Avenue
MADISON, WV 25130
Medicare Provider Number
511313
Participating Start Date
1/1/2011
Last Recertification Date
9/5/2024
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
1/13/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Virgil Lee Underwood, CEO
(304) 369-1230 Ext: 5507
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
1/13/2023
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