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Walmart Pharmacy 10-7611
CAH261306-00 SULLIVAN COUNTY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
SULLIVAN COUNTY MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH261306-00
Entity Address
630 WEST THIRD STREET
MILAN, MO 63556
Medicare Provider Number
261306
Participating Start Date
10/1/2015
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
Walmart Pharmacy 10-7611
Pharmacy Address
2501 Perry Rd
Plainfield, IN 46168
Pharmacy Comments
Contract Details
Approval Date
1/31/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Martha Gragg, CEO
(660) 265-4212 Ext: 610
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
1/31/2024
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