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WAL-MART PHARMACY 10-1542
SCH230133-00 MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
MUNSON HEALTHCARE OTSEGO MEMORIAL HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH230133-00
Entity Address
825 N. CENTER AVENUE
GAYLORD, MI 49735
Medicare Provider Number
230133
Participating Start Date
8/11/2010
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1542
Pharmacy Address
950 EDLEWEISS PARKWAY
GAYLORD, MI 49735
Pharmacy Comments
Contract Details
Approval Date
7/28/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
THOMAS LEMON, CHIEF EXECUTIVE OFFICER
(989) 731-2215
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
7/28/2016
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