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WALMART PHARMACY 10-5169
DSH370089 TAHLEQUAH CITY HOSPITAL
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Covered Entity Details
Entity Name
TAHLEQUAH CITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH370089
Entity Address
1400 E DOWNING
TAHLEQUAH, OK 74464
Medicare Provider Number
370089
Participating Start Date
4/1/2023
Last Recertification Date
8/15/2024
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
3/6/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
JAMES BERRY, EXEC VICE PRESIDENT
(918) 453-2263
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/17/2023
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