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WALMART PHARMACY 10-5169
CAH261337-00 Missouri Baptist Hospital of Sullivan, DBA, Missouri Baptist Sullivan Hospital
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Covered Entity Details
Entity Name
Missouri Baptist Hospital of Sullivan, DBA, Missouri Baptist Sullivan Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH261337-00
Entity Address
751 Sappington Bridge Road
Sullivan, MO 63080
Medicare Provider Number
261337
Participating Start Date
1/1/2013
Last Recertification Date
8/26/2024
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
7/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Lisa Lynne Lochner, President
(573) 468-1285 Ext: 5734681345
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/5/2023
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