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WALMART PHARMACY 10-5169
CAH161372-00 BOONE COUNTY HOSPITAL
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Covered Entity Details
Entity Name
BOONE COUNTY HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161372-00
Entity Address
1015 UNION STREET
BOONE, IA 50036
Medicare Provider Number
161372
Participating Start Date
9/2/2010
Last Recertification Date
8/14/2024
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
7/11/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/30/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Mikaela Kienitz, CEO
(515) 433-8480
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
7/11/2023
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