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Walmart Pharmacy 10-7611
CAH241325-00 CCM Health
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Covered Entity Details
Entity Name
CCM Health
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241325-00
Entity Address
824 N 11Th St
Montevideo, MN 56265
Medicare Provider Number
241325
Participating Start Date
1/1/2012
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
Walmart Pharmacy 10-7611
Pharmacy Address
2501 Perry Rd
Plainfield, IN 46168
Pharmacy Comments
Contract Details
Approval Date
10/4/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brian Lovdahl, CEO
(320) 321-8101
Contract Pharmacy Representative
Walmart
Van Donn, Director of Contracting 340b
(303) 261-5549
Signed By Date
10/4/2023
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