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Walmart Pharmacy 10-7611
SCH530002-00 CAMPBELL COUNTY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
CAMPBELL COUNTY MEMORIAL HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH530002-00
Entity Address
501 S BURMA AVENUE
GILLETTE, WY 82717-3011
Medicare Provider Number
530002
Participating Start Date
3/15/2022
Last Recertification Date
9/26/2023
Entity Termination Date
4/1/2024
Pharmacy Details
Pharmacy Name
Walmart Pharmacy 10-7611
Pharmacy Address
2501 Perry Rd
Plainfield, IN 46168
Pharmacy Comments
Contract Details
Approval Date
10/23/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Matthew Shahan, CEO
(307) 688-1551
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
10/23/2023
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