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WAL-MART PHARMACY 10-4247
DSH270032 NORTHERN MONTANA HOSPITAL
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Covered Entity Details
Entity Name
NORTHERN MONTANA HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH270032
Entity Address
30-13TH STREET
HAVRE, MT 59501
Medicare Provider Number
270032
Participating Start Date
10/1/2009
Last Recertification Date
9/5/2023
Entity Termination Date
1/1/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-4247
Pharmacy Address
3510 HIGHWAY 2 WEST
HAVRE, MT 59501
Pharmacy Comments
Contract Details
Approval Date
1/17/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/6/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
DAVID C. HENRY, PRESIDENT/CEO
(406) 262-1302
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
1/17/2017
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