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WALMART PHARMACY 10-5169
DSH260160 SOUTHEASTHEALTH CENTER OF STODDARD CTY; dba MERCY HOSPITAL STODDARD
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Covered Entity Details
Entity Name
SOUTHEASTHEALTH CENTER OF STODDARD CTY; dba MERCY HOSPITAL STODDARD
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260160
Entity Address
1200 NORTH ONE MILE ROAD
DEXTER, MO 63841
Medicare Provider Number
260160
Participating Start Date
7/1/2019
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
Contacts
Covered Entity Signing Official
Sue Ann Williams, CEO
(573) 614-1900
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/16/2023
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