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WALMART PHARMACY 10-5169
DSH380056 SANTIAM MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
SANTIAM MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH380056
Entity Address
1401 NORTH 10TH AVE
STAYTON, OR 97383
Medicare Provider Number
380056
Participating Start Date
7/1/2021
Last Recertification Date
8/14/2024
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
2/12/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Maggie Ann Hudson, CEO
(503) 769-9236
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/17/2023
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