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WALMART PHARMACY 10-5169
CAH431340-00 AVERA QUEEN OF PEACE
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Covered Entity Details
Entity Name
AVERA QUEEN OF PEACE
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH431340-00
Entity Address
525 North Foster
Mitchell, SD 57301
Medicare Provider Number
431340
Participating Start Date
4/5/2023
Last Recertification Date
8/28/2024
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
4/5/2023
Contract Begin Date
4/5/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Melissa Goff, Vice President - Pharmacy
(605) 322-8548
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
4/5/2023
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