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Walmart Pharmacy 10-7611
SCH270003-00 ST. PETERS HEALTH
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Covered Entity Details
Entity Name
ST. PETERS HEALTH
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH270003-00
Entity Address
2475 E Broadway St.
HELENA, MT 59601
Medicare Provider Number
270003
Participating Start Date
3/15/2022
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
Walmart Pharmacy 10-7611
Pharmacy Address
2501 Perry Rd
Plainfield, IN 46168
Pharmacy Comments
Contract Details
Approval Date
10/17/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Nathan M Coburn, CFO
(406) 444-2122
Contract Pharmacy Representative
Walmart
Jodi Prohofsky, Sr. Director
(479) 277-1498
Signed By Date
10/17/2023
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