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WALMART PHARMACY 10-5169
CAH151304-00 RUSH MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
RUSH MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH151304-00
Entity Address
1300 N. MAIN STREET
RUSHVILLE, IN 46173
Medicare Provider Number
151304
Participating Start Date
8/30/2010
Last Recertification Date
8/27/2024
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
10/6/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
BRADLEY SMITH, CEO
(765) 932-7513
Contract Pharmacy Representative
Walmart
Vann Donn, contracting
(479) 202-7198
Signed By Date
10/6/2023
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