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WALMART PHARMACY 10-5169
CAH171301-00 GREAT PLAINS OF ELLINWOOD INC.
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Covered Entity Details
Entity Name
GREAT PLAINS OF ELLINWOOD INC.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH171301-00
Entity Address
300 N Park
ELLINWOOD, KS 67526
Medicare Provider Number
171301
Participating Start Date
1/1/2018
Last Recertification Date
8/27/2024
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
3/22/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kile Neal Magner, CEO
(620) 564-2548
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
4/17/2023
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