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WALMART PHARMACY 10-5169
CAH511319-00 JEFFERSON MEDICAL CENTER
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Covered Entity Details
Entity Name
JEFFERSON MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH511319-00
Entity Address
300 S. PRESTON STREET
RANSON, WV 25438-1631
Medicare Provider Number
511319
Participating Start Date
9/29/2010
Last Recertification Date
8/21/2024
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
Grover Glendon Kerns, VP of Finance
(304) 260-1443
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
1/17/2023
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