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WALMART PHARMACY 10-5169
DSH240084 ESSENTIA HEALTH VIRGINIA
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Covered Entity Details
Entity Name
ESSENTIA HEALTH VIRGINIA
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH240084
Entity Address
901 9TH STREET NORTH
VIRGINIA, MN 55792-2398
Medicare Provider Number
240084
Participating Start Date
1/1/2021
Last Recertification Date
9/3/2024
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
7/8/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Sam Stone, COO
(218) 742-8600 Ext: 2496
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
7/8/2023
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