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Walmart Pharmacy 10-7611
DSH040069 GREAT RIVER MEDICAL CENTER
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Covered Entity Details
Entity Name
GREAT RIVER MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH040069
Entity Address
1520 NORTH DIVISION ST
BLYTHEVILLE, AR 72315
Medicare Provider Number
040069
Participating Start Date
4/1/2020
Last Recertification Date
8/27/2024
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
Bryan Hargis, CEO
(870) 838-7461
Contract Pharmacy Representative
Great River Medical Center
Melissa Joy, Pharmacist in Charge
(870) 838-7241
Signed By Date
10/10/2023
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