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WAL-MART PHARMACY 10-1230
CAH031315-00 WHITE MOUNTAIN REGIONAL HOSPITAL
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Covered Entity Details
Entity Name
WHITE MOUNTAIN REGIONAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH031315-00
Entity Address
118 SOUTH MOUNTAIN AVE
SPRINGERVILLE, AZ 85938
Medicare Provider Number
031315
Participating Start Date
4/1/2017
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1230
Pharmacy Address
5401 S. WHITE MOUNTAIN ROAD
SHOW LOW, AZ 85901
Pharmacy Comments
Contract Details
Approval Date
4/18/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Wesley Babers, CEO
(928) 333-7178
Contract Pharmacy Representative
Walmart
Nick Tallman, Senior Director of Mechandising
(479) 371-0431
Signed By Date
4/18/2025
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