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Walmart Pharmacy 10-7611
SCH460019-00 Uintah Basin Medical Center
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Covered Entity Details
Entity Name
Uintah Basin Medical Center
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH460019-00
Entity Address
250 West 300 North
Roosevelt, UT 84066
Medicare Provider Number
460019
Participating Start Date
7/1/2012
Last Recertification Date
8/12/2024
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
Brent Hales, CFO
(435) 722-6164
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
10/10/2023
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