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Walmart Pharmacy 10-7611
SCH160005-00 ST. ANTHONY REGIONAL HOSPITAL
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Covered Entity Details
Entity Name
ST. ANTHONY REGIONAL HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH160005-00
Entity Address
311 SOUTH CLARK STREET
CARROLL, IA 51401
Medicare Provider Number
160005
Participating Start Date
10/1/2017
Last Recertification Date
9/12/2023
Entity Termination Date
5/22/2024
Pharmacy Details
Pharmacy Name
Walmart Pharmacy 10-7611
Pharmacy Address
2501 Perry Rd
Plainfield, IN 46168
Pharmacy Comments
Contract Details
Approval Date
10/13/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/22/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Eric Clark Salmonson, CFO
(712) 794-5424
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
10/13/2023
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