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WAL-MART PHARMACY 10-0095
CH078000 GREAT MINES HEALTH CENTER
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Covered Entity Details
Entity Name
GREAT MINES HEALTH CENTER
Subdivision Name
Great Mines Health Center
Type
HRSA-Funded Health Center
340B ID
CH078000
Entity Address
#1 Southtowne Dr.
Potosi, MO 63664
Grant Number
H80CS06670
Participating Start Date
4/1/2005
Last Recertification Date
2/10/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0095
Pharmacy Address
407 N. STATE ST
DESLOGE, MO 63601
Pharmacy Comments
Contract Details
Approval Date
10/16/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2024
Agreement registered in error
Contacts
Covered Entity Signing Official
Gregory Roeback, Chief Executive Officer
(573) 438-8380
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager
(479) 277-1498
Signed By Date
10/16/2023
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