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WALMART PHARMACY 10-5169
DSH520087 Gundersen Lutheran Medical Center, Inc.
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Covered Entity Details
Entity Name
Gundersen Lutheran Medical Center, Inc.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH520087
Entity Address
1900 South Ave
La Crosse, WI 54601
Medicare Provider Number
520087
Participating Start Date
7/1/2012
Last Recertification Date
9/6/2024
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
4/9/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Michelle Micka, VP Finance
(608) 775-3131 Ext: 53131
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/9/2025
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