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WAL-MART PHARMACY 10-0103
DSH370149 St. Anthony Shawnee Hospital
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Covered Entity Details
Entity Name
St. Anthony Shawnee Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH370149
Entity Address
1102 W MacArthur St
SHAWNEE, OK 74804
Medicare Provider Number
370149
Participating Start Date
4/1/2010
Last Recertification Date
9/1/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0103
Pharmacy Address
196 SHAWNEE MALL DR
SHAWNEE, OK 74804
Pharmacy Comments
Contract Details
Approval Date
4/17/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Charles Skillings, CEO
(405) 878-8110
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
4/17/2017
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