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WAL-MART PHARMACY 10-0027
CHC26564-07 South Central Missouri Community Health Center
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Covered Entity Details
Entity Name
South Central Missouri Community Health Center
Subdivision Name
Four Rivers Community Health Center Mobile Medical
Type
HRSA-Funded Health Center
340B ID
CHC26564-07
Entity Address
1081 E 18th St
Rolla, MO 65401-2448
Grant Number
H80CS26564
Participating Start Date
1/1/2022
Last Recertification Date
2/20/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0027
Pharmacy Address
1101 HWY 32 WEST
SALEM, MO 65560
Pharmacy Comments
Contract Details
Approval Date
1/3/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Stuart Hunter Gipson, CEO
(417) 576-7273
Contract Pharmacy Representative
Walmart
Van Donn, 340B Director Contracting
(479) 273-4000
Signed By Date
1/3/2024
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