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WALMART PHARMACY 10-5169
SCH260050-00 Mosaic Medical Center Maryville
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Covered Entity Details
Entity Name
Mosaic Medical Center Maryville
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH260050-00
Entity Address
2016 S. Main
Maryville, MO 64468
Medicare Provider Number
260050
Participating Start Date
10/1/2013
Last Recertification Date
8/19/2024
Entity Termination Date
4/1/2025
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
7/3/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Edward P Kammerer, 340B Administrator
(816) 271-1236
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
7/3/2024
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