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WAL-MART PHARMACY 10-0009
DSH260113 MISSOURI DELTA MEDICAL CENTER
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Covered Entity Details
Entity Name
MISSOURI DELTA MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260113
Entity Address
1008 NORTH MAIN
SIKESTON, MO 63801
Medicare Provider Number
260113
Participating Start Date
7/1/2006
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0009
Pharmacy Address
1303 S MAIN ST
SIKESTON, MO 63801
Pharmacy Comments
Contract Details
Approval Date
2/1/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
JASON SCHRUMPF, CEO
(573) 472-7600
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/15/2013
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