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WAL-MART PHARMACY 10-0062
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 10-0062
Pharmacy Address
3700 EAST HIGHWAY 18
BLYTHEVILLE, AR 72315
Pharmacy Comments
Contract Details
Approval Date
1/9/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
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
1/9/2017
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