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WAL-MART PHARMACY 10-0031
DSH040055 Baptist Health - Fort Smith
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Covered Entity Details
Entity Name
Baptist Health - Fort Smith
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH040055
Entity Address
1001 TOWSON AVE
FORT SMITH, AR 72901
Medicare Provider Number
040055
Participating Start Date
10/1/2019
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0031
Pharmacy Address
3108 N. BROADWAY
POTEAU, OK 74953
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
11/1/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Brent Beaulieu, CFO
(501) 202-2017
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
1/17/2023
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