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WALMART PHARMACY 10-5169
CAH221303-00 Athol Memorial Hospital
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Covered Entity Details
Entity Name
Athol Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH221303-00
Entity Address
2033 Main St.
Athol, MA 01331
Medicare Provider Number
221303
Participating Start Date
4/1/2013
Last Recertification Date
9/4/2024
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
Contract Termination Date
Termination Reason
4/14/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Tom Sullivan, CFO
(978) 630-6157
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/17/2023
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