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WALMART PHARMACY 10-5169
CAH151322-00 PERRY COUNTY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
PERRY COUNTY MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH151322-00
Entity Address
8885 State Road 237
TELL CITY, IN 47586
Medicare Provider Number
151322
Participating Start Date
7/1/2011
Last Recertification Date
9/6/2024
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
7/14/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kayla Gehlhausen, Chief Nursing Officer
(812) 547-0235
Contract Pharmacy Representative
Walmart
Van Donn, 340B Director Contracting
(479) 273-4000
Signed By Date
7/14/2023
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