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WAL-MART PHARMACY 10-5863
DSH370094 SSM Health St Anthony Hospital - Midwest
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Covered Entity Details
Entity Name
SSM Health St Anthony Hospital - Midwest
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH370094
Entity Address
2825 Parklawn Dr
MIDWEST CITY, OK 73110
Medicare Provider Number
370094
Participating Start Date
4/1/2022
Last Recertification Date
8/31/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5863
Pharmacy Address
7520 E RENO AVE
MIDWEST CITY, OK 73110
Pharmacy Comments
Contract Details
Approval Date
7/15/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Shasta Manuel, VP of Finance CFO
(405) 272-7282
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
7/15/2024
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