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WAL-MART PHARMACY 10-1389
CAH161372-00 BOONE COUNTY HOSPITAL
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Covered Entity Details
Entity Name
BOONE COUNTY HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161372-00
Entity Address
1015 UNION STREET
BOONE, IA 50036
Medicare Provider Number
161372
Participating Start Date
9/2/2010
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1389
Pharmacy Address
1515 SE MARSHALL STREET
BOONE, IA 50036
Pharmacy Comments
Contract Details
Approval Date
8/24/2012
Contract Begin Date
9/1/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/30/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
David Mellet, Chief Financial Officer
(515) 433-8461
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
8/16/2012
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