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WALMART PHARMACY 10-5169
SCH160005-00 ST. ANTHONY REGIONAL HOSPITAL
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Covered Entity Details
Entity Name
ST. ANTHONY REGIONAL HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH160005-00
Entity Address
311 SOUTH CLARK STREET
CARROLL, IA 51401
Medicare Provider Number
160005
Participating Start Date
10/1/2017
Last Recertification Date
9/12/2023
Entity Termination Date
5/22/2024
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
Contract Termination Date
Termination Reason
5/22/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Eric Clark Salmonson, CFO
(712) 794-5424
Contract Pharmacy Representative
Walmart
Tisha Campbell, Director of Contracting
(949) 872-4138
Signed By Date
4/5/2023
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