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WAL-MART PHARMACY 10-3245
RRC240047-00 ST. LUKES HOSPITAL OF DULUTH
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Covered Entity Details
Entity Name
ST. LUKES HOSPITAL OF DULUTH
Subdivision Name
Type
Rural Referral Center
340B ID
RRC240047-00
Entity Address
915 EAST FIRST STREET
DULUTH, MN 55805
Medicare Provider Number
240047
Participating Start Date
1/1/2025
Last Recertification Date
Entity Termination Date
1/1/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3245
Pharmacy Address
15594 STATE HIGHWAY 77
HAYWARD, WI 54843
Pharmacy Comments
Contract Details
Approval Date
10/22/2024
Contract Begin Date
1/1/2025
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2025
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Michael Boeselager, Vice President Support Services
(218) 249-2459
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/15/2024
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