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WALMART PHARMACY 10-5169
DSH320084 ROOSEVELT GENERAL HOSPITAL
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Covered Entity Details
Entity Name
ROOSEVELT GENERAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH320084
Entity Address
42121 US HIGHWAY 70
PORTALES, NM 88130
Medicare Provider Number
320084
Participating Start Date
1/1/2017
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
Contacts
Covered Entity Signing Official
Andrea King, CFO
(575) 356-3406
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
4/14/2023
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