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Walmart Pharmacy 10-7611
CAH281304-00 Thayer County Memorial Hospital dba Thayer County Health Services
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Covered Entity Details
Entity Name
Thayer County Memorial Hospital dba Thayer County Health Services
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH281304-00
Entity Address
120 Park Avenue
Hebron, NE 68370
Medicare Provider Number
281304
Participating Start Date
4/1/2013
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
Walmart Pharmacy 10-7611
Pharmacy Address
2501 Perry Rd
Plainfield, IN 46168
Pharmacy Comments
Contract Details
Approval Date
10/10/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brian P Rokusek, President
(402) 768-4614
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
10/10/2023
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