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Walmart Pharmacy 10-7611
CAH241359-00 AVERA MARSHALL
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Covered Entity Details
Entity Name
AVERA MARSHALL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241359-00
Entity Address
300 S BRUCE STREET
MARSHALL, MN 56258-1934
Medicare Provider Number
241359
Participating Start Date
9/28/2010
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
Walmart Pharmacy 10-7611
Pharmacy Address
2501 Perry Rd
Plainfield, IN 46168
Pharmacy Comments
Contract Details
Approval Date
10/12/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Melissa Goff, Vice President - Pharmacy
(605) 322-8548
Contract Pharmacy Representative
Walmart
Tisha Campbell, Director of Contracting
(949) 872-4138
Signed By Date
10/12/2023
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