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WALMART PHARMACY 10-5169
CAH521318-00 LADD MEMORIAL HOSPITAL DBA OSCEOLA MEDICAL CENTER
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Covered Entity Details
Entity Name
LADD MEMORIAL HOSPITAL DBA OSCEOLA MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521318-00
Entity Address
2600 65TH AVE
OSCEOLA, WI 54020
Medicare Provider Number
521318
Participating Start Date
1/1/2011
Last Recertification Date
8/15/2024
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
Contract Termination Date
Termination Reason
9/26/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kelly Macken-Marble, Chief Executive Officer
(715) 294-5622
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
4/14/2023
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