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WAL-MART PHARMACY 10-0985
CAH161364-00 JEFFERSON COUNTY HEALTH CENTER
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Covered Entity Details
Entity Name
JEFFERSON COUNTY HEALTH CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161364-00
Entity Address
2000 SOUTH MAIN STREET
FAIRFIELD, IA 52556
Medicare Provider Number
161364
Participating Start Date
8/24/2010
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0985
Pharmacy Address
2701 W. BURLINGTON AVE.
FAIRFIELD, IA 52556
Pharmacy Comments
Contract Details
Approval Date
11/9/2012
Contract Begin Date
11/9/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Roddey Gettys, CEO
(864) 552-7606
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
9/27/2012
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