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WALMART PHARMACY 10-5169
CAH161363-00 Montgomery County Memorial Hospital
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Covered Entity Details
Entity Name
Montgomery County Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161363-00
Entity Address
2301 Eastern Avenue
Red Oak, IA 51566
Medicare Provider Number
161363
Participating Start Date
4/1/2012
Last Recertification Date
8/13/2024
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
Bryant John Blay, CFO
(712) 623-7152
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
4/14/2023
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