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WALMART PHARMACY 10-5169
CAH521319-00 EDGERTON HOSPITAL & HEALTH SERVICES
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Covered Entity Details
Entity Name
EDGERTON HOSPITAL & HEALTH SERVICES
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH521319-00
Entity Address
11101 N SHERMAN ROAD
EDGERTON, WI 53534
Medicare Provider Number
521319
Participating Start Date
10/1/2015
Last Recertification Date
9/9/2024
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
Charles Roeder, Vice President/CFO
(608) 884-1656
Contract Pharmacy Representative
Edgerton Hospital
Diane Pfister Whitley, Director of Pharmacy
(608) 884-1586
Signed By Date
7/15/2024
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