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Walmart Pharmacy 10-7611
CAH141311-00 FAIRFIELD MEMORIAL HOSPITAL ASSOCIATION
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Covered Entity Details
Entity Name
FAIRFIELD MEMORIAL HOSPITAL ASSOCIATION
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH141311-00
Entity Address
303 NW 11TH STREET
FAIRFIELD, IL 62837
Medicare Provider Number
141311
Participating Start Date
7/1/2011
Last Recertification Date
8/12/2024
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
Kristin Boldt, Controller
(618) 847-8244
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/4/2023
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