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WALMART PHARMACY 10-5169
DSH260105 SSM HEALTH SAINT LOUIS UNIVERSITY HOSPITAL
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Covered Entity Details
Entity Name
SSM HEALTH SAINT LOUIS UNIVERSITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260105
Entity Address
1201 South Grand Blvd.
ST. LOUIS, MO 63104
Medicare Provider Number
260105
Participating Start Date
4/1/2016
Last Recertification Date
8/15/2024
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
10/11/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Eileen Lamm, Regional Vice President-Finance
(314) 994-6219
Contract Pharmacy Representative
Walmart
Van Donn, 340B Director Contracting
(479) 273-4000
Signed By Date
10/11/2023
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