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WAL-MART PHARMACY 10-0166
CAH261318-00 SALEM MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
SALEM MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH261318-00
Entity Address
35629 HIGHWAY 72
SALEM, MO 65560-0774
Medicare Provider Number
261318
Participating Start Date
1/1/2011
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0166
Pharmacy Address
1433 SOUTH SAM HOUSTON BLVD.
HOUSTON, MO 65483
Pharmacy Comments
Contract Details
Approval Date
7/20/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/3/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
KASEY LUCAS, ASSISTANT ADMINISTRATOR
(573) 729-5917 Ext: 4003
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
7/20/2015
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