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WALMART PHARMACY 10-5169
CAH161380-00 ELLSWORTH MUNICIPAL HOSPITAL
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Covered Entity Details
Entity Name
ELLSWORTH MUNICIPAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161380-00
Entity Address
920 S OAK ST
DBA HANSEN FAMILY HOSPITAL
IOWA FALLS, IA 50126-9506
Medicare Provider Number
161380
Participating Start Date
9/1/2010
Last Recertification Date
8/21/2024
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
10/9/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
George Von Mock, CEO
(641) 648-7010
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/9/2023
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