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WALMART PHARMACY 10-5169
CAH531315-00 South Lincoln Hospital District
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Covered Entity Details
Entity Name
South Lincoln Hospital District
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH531315-00
Entity Address
711 Onyx Street
Kemmerer, WY 83101-3214
Medicare Provider Number
531315
Participating Start Date
10/1/2012
Last Recertification Date
8/29/2024
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
7/3/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Dave Ryerse, CEO
(307) 800-8650
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
7/3/2023
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