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WALMART PHARMACY 10-5169
DSH270049 Intermountain Health St Vincent Regional Hospital
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Covered Entity Details
Entity Name
Intermountain Health St Vincent Regional Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH270049
Entity Address
1233 N. 30th Street
Billings, MT 59101
Medicare Provider Number
270049
Participating Start Date
10/1/2012
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
2/16/2023
Contract Begin Date
2/16/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/25/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Pam Palagi, VP Financial Services
(406) 723-2414
Contract Pharmacy Representative
Walmart
Van Donn, Director of Contracting 340b
(303) 261-5549
Signed By Date
2/16/2023
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