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WALMART PHARMACY 10-5169
DSH110132 MEMORIAL HOSPITAL AND MANOR
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Covered Entity Details
Entity Name
MEMORIAL HOSPITAL AND MANOR
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110132
Entity Address
1500 E SHOTWELL STREET
BAINBRIDGE, GA 39819
Medicare Provider Number
110132
Participating Start Date
10/1/2004
Last Recertification Date
9/4/2024
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
4/14/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
James M Lambert, CEO
(229) 243-6105
Contract Pharmacy Representative
Walmart
Julie Howard, 340b Program Manager
(479) 739-1973 Ext: 4792771498
Signed By Date
4/14/2023
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