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WALMART PHARMACY 10-5169
CAH281319-00 JEFFERSON COMMUNITY HEALTH CENTER DBA JEFFERSON COMMUNITY HEALTH & LIFE
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Covered Entity Details
Entity Name
JEFFERSON COMMUNITY HEALTH CENTER DBA JEFFERSON COMMUNITY HEALTH & LIFE
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH281319-00
Entity Address
2200 H ST
FAIRBURY, NE 68352
Medicare Provider Number
281319
Participating Start Date
1/1/2011
Last Recertification Date
8/15/2024
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
7/6/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Chance Klasek, CFO
(402) 729-6856
Contract Pharmacy Representative
Walmart
Van Donn, Director of Contracting 340b
(303) 261-5549
Signed By Date
7/6/2023
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