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WALMART PHARMACY 10-5169
DSH230121 The Memorial Hospital d/b/a Memorial Healthcare
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Covered Entity Details
Entity Name
The Memorial Hospital d/b/a Memorial Healthcare
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230121
Entity Address
826 W. King Street
Owosso, MI 48867
Medicare Provider Number
230121
Participating Start Date
7/1/2014
Last Recertification Date
9/6/2024
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
1/17/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jorri Tremain, Chief Financial Officer
(989) 729-4466
Contract Pharmacy Representative
Wal-Mart
Vann Donn, 340B Director
(484) 773-1201
Signed By Date
1/17/2023
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