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Walmart Pharmacy 10-7611
DSH260142C JOHN FITZGIBBON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
JOHN FITZGIBBON MEMORIAL HOSPITAL
Subdivision Name
JOHN FITZGIBBON MEM HOSPITAL INC - Fitzgibbon Family Health
Type
Disproportionate Share Hospital
340B ID
DSH260142C
Entity Address
600 W MORRISON ST
STE 5
FAYETTE, MO 65248-1075
Medicare Provider Number
260142
Outpatient Facility Provider Number
268731
Participating Start Date
4/1/2022
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
Walmart Pharmacy 10-7611
Pharmacy Address
2501 Perry Rd
Plainfield, IN 46168
Pharmacy Comments
Contract Details
Approval Date
10/5/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Angy P. Littrell, President & CEO
(660) 831-3251
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
10/5/2023
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