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WAL-MART PHARMACY 10-0338
DSH260137 FREEMAN HEALTH SYSTEM
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Covered Entity Details
Entity Name
FREEMAN HEALTH SYSTEM
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260137
Entity Address
1102 WEST 32ND STREET
JOPLIN, MO 64804-3503
Medicare Provider Number
260137
Participating Start Date
4/1/2004
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0338
Pharmacy Address
29 SOUTHWEST FIRST LN
LAMAR, MO 64759
Pharmacy Comments
Contract Details
Approval Date
12/4/2012
Contract Begin Date
1/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/22/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
DEBI KOELKEBECK, VP, RETAIL/CLINICAL OPERATIONS
(417) 347-3074
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
10/29/2012
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