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WAL-MART PHARMACY 10-1787
CAH161382-00 ST. ANTHONY REGIONAL HOSPITAL
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Covered Entity Details
Entity Name
ST. ANTHONY REGIONAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161382-00
Entity Address
311 SOUTH CLARK STREET
CARROLL, IA 51401
Medicare Provider Number
161382
Participating Start Date
5/22/2024
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1787
Pharmacy Address
2014 KITTY HAWK AVE
CARROLL, IA 51401
Pharmacy Comments
Contract Details
Approval Date
5/22/2024
Contract Begin Date
5/22/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Eric Clark Salmonson, CFO
(712) 794-5424
Contract Pharmacy Representative
Walmart
Tisha Campbell, Director of Contracting
(949) 872-4138
Signed By Date
5/1/2024
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