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WAL-MART PHARMACY 10-0363
DSH260142 JOHN FITZGIBBON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
JOHN FITZGIBBON MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH260142
Entity Address
2305 SOUTH HIGHWAY 65
MARSHALL, MO 65340
Medicare Provider Number
260142
Participating Start Date
1/1/2020
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0363
Pharmacy Address
855 S. CHEROKEE DR.
MARSHALL, MO 65340
Pharmacy Comments
Contract Details
Approval Date
8/21/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2017
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Angy P. Littrell, President & CEO
(660) 831-3251
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
8/21/2015
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