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WAL-MART PHARMACY 10-0339
CH06273AA Mainline Health Systems Inc
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Covered Entity Details
Entity Name
Mainline Health Systems Inc
Subdivision Name
Brunson Elementary School Behavioral Health Clinic
Type
HRSA-Funded Health Center
340B ID
CH06273AA
Entity Address
212 Scoby Dr
Warren, AR 71671-2050
Grant Number
H80CS00638
Participating Start Date
10/1/2022
Last Recertification Date
2/24/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0339
Pharmacy Address
1123 HIGHWAY 79/167 BYPASS
PO BOX 705
FORDYCE, AR 71742
Pharmacy Comments
Contract Details
Approval Date
10/16/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
GARY ALLAN NICHOLS, Executive Director
(870) 538-5414
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/16/2023
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