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WALMART PHARMACY 10-5169
RRC150042-00 GOOD SAMARITAN HOSPITAL
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Covered Entity Details
Entity Name
GOOD SAMARITAN HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC150042-00
Entity Address
520 S. Seventh St.
VINCENNES, IN 47591
Medicare Provider Number
150042
Participating Start Date
7/1/2022
Last Recertification Date
8/19/2024
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
4/17/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/17/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Matthew S Schuckman, CFO
(812) 885-3334
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/17/2023
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