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WAL-MART PHARMACY 10-0820
DSH260009 BOTHWELL REGIONAL HEALTH CENTER
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Covered Entity Details
Entity Name
BOTHWELL REGIONAL HEALTH CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260009
Entity Address
601 E. 14TH STREET
SEDALIA, MO 65301
Medicare Provider Number
260009
Participating Start Date
10/1/2023
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0820
Pharmacy Address
2150 MAIN ST
BOONVILLE, MO 65233
Pharmacy Comments
Contract Details
Approval Date
4/10/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Steven R Davis, Chief Financial Officer
(660) 829-7790
Contract Pharmacy Representative
Walmart
Nick Tallman, Sr. Director, Merchandise Operations – Pharmacy
(479) 371-0417
Signed By Date
4/10/2025
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