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WALMART PHARMACY 10-5169
CAH161374-00 SHELBY CO CHRIS A MYRTUE MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
SHELBY CO CHRIS A MYRTUE MEMORIAL HOSPITAL
Subdivision Name
DBA MYRTUE MEDICAL CENTER
Type
Critical Access Hospital
340B ID
CAH161374-00
Entity Address
1213 GARFIELD AVE
HARLAN, IA 51537
Medicare Provider Number
161374
Participating Start Date
4/1/2011
Last Recertification Date
8/19/2024
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
1/19/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Barry Jacobsen, CEO
(712) 755-4315
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
1/19/2023
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