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WAL-MART PHARMACY 10-1929
CAH241364-00 COMMUNITY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
COMMUNITY MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241364-00
Entity Address
512 SKYLINE BOULEVARD
CLOQUET, MN 55720
Medicare Provider Number
241364
Participating Start Date
7/1/2019
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1929
Pharmacy Address
1308 HWY 33 SOUTH
CLOQUET, MN 55720
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
Brad K Anderson, CFO
(218) 878-7027
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
1/16/2024
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