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WALMART PHARMACY 10-5169
DSH510046 PRINCETON COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
PRINCETON COMMUNITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH510046
Entity Address
122 12TH STREET
PRINCETON, WV 24740
Medicare Provider Number
510046
Participating Start Date
1/1/2009
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
1/18/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Diane Lynn Spencer, VP of Finance/CFO
(304) 487-7505
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
1/18/2023
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