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WAL-MART PHARMACY 10-4272
RRC460015-00 LOGAN REGIONAL HOSPITAL
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Covered Entity Details
Entity Name
LOGAN REGIONAL HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC460015-00
Entity Address
1400 NORTH 500 EAST
LOGAN, UT 84341
Medicare Provider Number
460015
Participating Start Date
7/1/2025
Last Recertification Date
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-4272
Pharmacy Address
1150 S 100 W
LOGAN, UT 84321
Pharmacy Comments
Contract Details
Approval Date
4/25/2023
Contract Begin Date
4/25/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Justin Wiser, Finance Director
(435) 716-5331
Contract Pharmacy Representative
Wal-Mart
Julie Howard, 340B Program Manager
(479) 739-1973
Signed By Date
4/17/2023
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