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WAL-MART PHARMACY 10-0895
DSH260017 PHELPS COUNTY REGIONAL MEDICAL CNTR
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Covered Entity Details
Entity Name
PHELPS COUNTY REGIONAL MEDICAL CNTR
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260017
Entity Address
1000 WEST 10TH STREET
ROLLA, MO 65401
Medicare Provider Number
260017
Participating Start Date
3/2/2021
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0895
Pharmacy Address
100 OZARK DRIVE
CUBA, MO 65453
Pharmacy Comments
Contract Details
Approval Date
5/18/2023
Contract Begin Date
5/24/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jana Cook, Chief Financial Officer
(573) 458-7916
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
5/18/2023
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