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WAL-MART PHARMACY 10-5315
CAH531301-00 SOUTH BIG HORN HOSPITAL
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Covered Entity Details
Entity Name
SOUTH BIG HORN HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH531301-00
Entity Address
388 HWY 20 SOUTH
BASIN, WY 82410
Medicare Provider Number
531301
Participating Start Date
10/1/2017
Last Recertification Date
8/16/2023
Entity Termination Date
10/1/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
4/12/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Marion Anthony Thompson, InterimCEO
(307) 568-1426
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
4/12/2023
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