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WALMART PHARMACY 10-5169
CAH161375-00 BUENA VISTA REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
BUENA VISTA REGIONAL MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161375-00
Entity Address
1525 W. 5TH ST.
STORM LAKE, IA 50588
Medicare Provider Number
161375
Participating Start Date
8/18/2010
Last Recertification Date
8/26/2024
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
4/15/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Krista L. Ketcham, Chief Financial Officer
(712) 213-8603
Contract Pharmacy Representative
Buena Vista Regional Medical Center
JON David MCKENNA, DIRECTOR OF PHARMACY
(712) 213-8695
Signed By Date
4/15/2024
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