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WAL-MART PHARMACY 10-0101
CAH261318-00 SALEM MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
SALEM MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH261318-00
Entity Address
35629 HIGHWAY 72
SALEM, MO 65560-0774
Medicare Provider Number
261318
Participating Start Date
1/1/2011
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0101
Pharmacy Address
500 S BISHOP
ROLLA, MO 65401
Pharmacy Comments
Contract Details
Approval Date
4/2/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brooke Bollman, CEO
(573) 729-6626 Ext: 4000
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
4/2/2025
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