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WALMART PHARMACY 10-5169
DSH150072 MEMORIAL HOSPITAL LOGANSPORT
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Covered Entity Details
Entity Name
MEMORIAL HOSPITAL LOGANSPORT
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH150072
Entity Address
1101 MICHIGAN AVENUE
LOGANSPORT, IN 46947
Medicare Provider Number
150072
Participating Start Date
4/1/2023
Last Recertification Date
8/27/2024
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
Perry Gay, CEO
(574) 753-1385
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/17/2023
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