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WALMART PHARMACY 10-3654
CAH451303-03 LIMESTONE MEDICAL CENTER
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Covered Entity Details
Entity Name
LIMESTONE MEDICAL CENTER
Subdivision Name
SOUTH LIMESTONE HOSPITAL DISTRICT - KOSSE COMMUNITY HEALTH CLINIC (RHC)
Type
Critical Access Hospital
340B ID
CAH451303-03
Entity Address
206 N NARCISSUS
KOSSE COMM HEALTH CLC A LMC CLINIC
KOSSE, TX 76653-3538
Medicare Provider Number
451303
Outpatient Facility Provider Number
673482
Participating Start Date
7/1/2022
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-3654
Pharmacy Address
808 WEST WALNUT STREET
ROGERS, AR 72756
Pharmacy Comments
Contract Details
Approval Date
1/9/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/16/2024
OPA Terminated due to audit finding
Contacts
Covered Entity Signing Official
Larry N. Price, CEO/ADMINISTRATOR
(254) 729-3281 Ext: 2100
Contract Pharmacy Representative
Walmart
Julie Howard, Manager Contracting & Channel Management
(479) 277-3719
Signed By Date
1/9/2024
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