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WAL-MART PHARMACY 10-0088
DSH260078 Ozarks Medical Center DBA Ozarks Healthcare
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Covered Entity Details
Entity Name
Ozarks Medical Center DBA Ozarks Healthcare
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260078
Entity Address
1100 KENTUCKY AVENUE
WEST PLAINS, MO 65775-1100
Medicare Provider Number
260078
Participating Start Date
1/1/2005
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0088
Pharmacy Address
2100 N MAIN
MOUNTAIN GROVE, MO 65711
Pharmacy Comments
Contract Details
Approval Date
4/3/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kim Thompson, CFO
(417) 256-9111 Ext: 6031
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
4/3/2015
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