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WALMART PHARMACY 10-5169
DSH130025 MADISON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
MADISON MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH130025
Entity Address
450 EAST MAIN
REXBURG, ID 83440
Medicare Provider Number
130025
Participating Start Date
7/1/2009
Last Recertification Date
8/21/2024
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
Rachel Gonzales, CEO
(208) 356-3691
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/14/2023
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