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Walmart Pharmacy 10-7611
CAH521320-00 TOMAH MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
TOMAH MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521320-00
Entity Address
501 Gopher Drive
TOMAH, WI 54660-4513
Medicare Provider Number
521320
Participating Start Date
7/1/2020
Last Recertification Date
8/15/2024
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
Contract Termination Date
Termination Reason
7/7/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Joseph Zeps, CFO
(608) 372-2181
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/12/2023
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