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WAL-MART PHARMACY #10-0172
CAH261314-00 HERMANN AREA HOSPITAL DISTRICT
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Covered Entity Details
Entity Name
HERMANN AREA HOSPITAL DISTRICT
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH261314-00
Entity Address
509 WEST 18TH STREET
HERMANN, MO 65041
Medicare Provider Number
261314
Participating Start Date
8/11/2010
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY #10-0172
Pharmacy Address
1701 A ROY DRIVE
WASHINGTON, MO 63090
Pharmacy Comments
Contract Details
Approval Date
4/8/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/15/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
DAN MCKINNEY, ADMINISTRATOR
(573) 486-2191 Ext: 216
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
4/8/2013
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