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WAL-MART PHARMACY 10-0326
DSH260142D JOHN FITZGIBBON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
JOHN FITZGIBBON MEMORIAL HOSPITAL
Subdivision Name
JOHN FITZGIBBON HOSPITAL INC - Pilot Grove Medical Clinic
Type
Disproportionate Share Hospital
340B ID
DSH260142D
Entity Address
212 COLLEGE ST
PILOT GROVE MEDICAL CLINIC AT FITZG
PILOT GROVE, MO 65276-1005
Medicare Provider Number
260142
Outpatient Facility Provider Number
268790
Participating Start Date
1/1/2024
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0326
Pharmacy Address
1180 W 19TH STREET
HIGGINSVILLE, MO 64037
Pharmacy Comments
Contract Details
Approval Date
11/2/2023
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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