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WALMART PHARMACY 10-5169
FQHC638549 mathiesen memorial Health Clinic
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Covered Entity Details
Entity Name
mathiesen memorial Health Clinic
Subdivision Name
Type
Tribal Contract/Compact with IHS (P.L. 93-638)
340B ID
FQHC638549
Entity Address
18144 Seco Street
Jamestown, CA 95327
Grant Number
Participating Start Date
4/1/2018
Last Recertification Date
2/28/2025
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
Contacts
Covered Entity Signing Official
John Richard Vass, CEO
(209) 984-4827 Ext: 2099844827
Contract Pharmacy Representative
Walmart
Van Donn, Director of Contracting
(479) 277-3719
Signed By Date
10/13/2023
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