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WALMART PHARMACY 10-5169
SCH450241-00 FAITH COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
FAITH COMMUNITY HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH450241-00
Entity Address
215 Chisholm Trail
JACKSBORO, TX 76458
Medicare Provider Number
450241
Participating Start Date
1/1/2017
Last Recertification Date
8/23/2024
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
1/16/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/5/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kim Lee, COO
(940) 216-2225
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/16/2023
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