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WAL-MART PHARMACY 10-0156
DSH260070 PEMISCOT COUNTY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
PEMISCOT COUNTY MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260070
Entity Address
946 East Reed
HAYTI, MO 63851
Medicare Provider Number
260070
Participating Start Date
1/1/2015
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0156
Pharmacy Address
STATE HWY 84 WEST
PO BOX 971
CARUTHERSVILLE, MO 63830
Pharmacy Comments
Contract Details
Approval Date
1/20/2015
Contract Begin Date
4/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/8/2017
Pharmacy closed
Contacts
Covered Entity Signing Official
KERRY L. NOBLE, CEO
(573) 359-3612
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
1/20/2015
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