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WALMART PHARMACY 10-5169
CAH201303-00 PENOBSCOT VALLEY HOSPITAL
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Covered Entity Details
Entity Name
PENOBSCOT VALLEY HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH201303-00
Entity Address
7 TRANSALPINE ROAD
LINCOLN, ME 04457
Medicare Provider Number
201303
Participating Start Date
4/1/2011
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-5169
Pharmacy Address
2252 NORTH 8TH STREET
SUITE A
ROGERS, AR 72756
Pharmacy Comments
Contract Details
Approval Date
1/16/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Amy Theriault, Chief Operating Officer
(207) 794-3321
Contract Pharmacy Representative
Walmart
Van Donn, Director of Contracting
(479) 277-3719
Signed By Date
1/16/2024
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