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PPG STORE 1, LLC
CAH041305-00 MERCY HOSPITAL WALDRON
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Covered Entity Details
Entity Name
MERCY HOSPITAL WALDRON
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH041305-00
Entity Address
1341 WEST 6TH ST.
WALDRON, AR 72958-2230
Medicare Provider Number
041305
Participating Start Date
7/1/2024
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
PPG STORE 1, LLC
Pharmacy Address
DBA: HEARTLAND PHARMACY MANSFIELD
607 HIGHWAY 71 E
SUITE B
MANSFIELD, AR 72944
Pharmacy Comments
Contract Details
Approval Date
1/15/2025
Contract Begin Date
4/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Sherry Clouse Day, VP Finance - Mercy CAH
(417) 820-8439
Contract Pharmacy Representative
Heartland Pharmacy
Clint Boone, Principal-Pharmacy Manager
(479) 269-6161
Signed By Date
1/15/2025
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