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Walmart Pharmacy 10-7611
CAH171387-00 Coffeyville Regional Medical Center
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Covered Entity Details
Entity Name
Coffeyville Regional Medical Center
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH171387-00
Entity Address
1400 W 4th St.
Coffeyville, KS 67337
Medicare Provider Number
171387
Participating Start Date
5/13/2024
Last Recertification Date
8/18/2024
Pharmacy Details
Pharmacy Name
Walmart Pharmacy 10-7611
Pharmacy Address
2501 Perry Rd
Plainfield, IN 46168
Pharmacy Comments
Contract Details
Approval Date
5/13/2024
Contract Begin Date
5/13/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brian Heath Lawrence, CEO
(620) 252-1519
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
4/5/2024
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