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WALMART PHARMACY 10-5169
CAH031318-00 BANNER PAYSON MEDICAL CENTER
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Covered Entity Details
Entity Name
BANNER PAYSON MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH031318-00
Entity Address
807 S. PONDEROSA
PAYSON, AZ 85541
Medicare Provider Number
031318
Participating Start Date
1/1/2020
Last Recertification Date
8/20/2024
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
7/15/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Matthew K King, Senior Finance Director
(801) 682-9661
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
7/15/2024
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