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WALMART PHARMACY 10-5169
SCH450573-00 JASPER MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
JASPER MEMORIAL HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH450573-00
Entity Address
1275 MARVIN HANCOCK DR
JASPER, TX 75951
Medicare Provider Number
450573
Participating Start Date
1/1/2025
Last Recertification Date
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
10/21/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Nikki Martin, Regional Director, Finance
(409) 899-7105
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/4/2024
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