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WALMART PHARMACY 10-5169
DSH420051 MCLEOD REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
MCLEOD REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH420051
Entity Address
555 EAST CHEVES STREET
FLORENCE, SC 29506
Medicare Provider Number
420051
Participating Start Date
7/1/2006
Last Recertification Date
9/5/2024
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
10/13/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/17/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
S. Fulton Ervin, III, Senior Vice President Finance and Chief Financial Officer
(843) 777-2917
Contract Pharmacy Representative
Walmart
Van Donn, 340B Director Contracting
(479) 273-4000
Signed By Date
10/13/2023
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