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WAL-MART PHARMACY 10-2820
DSH240022 SANFORD WORTHINGTON MEDICAL CENTER
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Covered Entity Details
Entity Name
SANFORD WORTHINGTON MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH240022
Entity Address
1018 6TH AVENUE
WORTHINGTON, MN 56187-0097
Medicare Provider Number
240022
Participating Start Date
1/1/2010
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2820
Pharmacy Address
1055 Ryan Road
Worthington, MN 56187
Pharmacy Comments
Contract Details
Approval Date
1/12/2016
Contract Begin Date
4/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
LINDA WAGNER, Director of Fiscal Services
(507) 372-2941 Ext: 3112
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
1/12/2016
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