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WAL-MART PHARMACY 10-1722
CAH241359-00 AVERA MARSHALL
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Covered Entity Details
Entity Name
AVERA MARSHALL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241359-00
Entity Address
300 S BRUCE STREET
MARSHALL, MN 56258-1934
Medicare Provider Number
241359
Participating Start Date
9/28/2010
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1722
Pharmacy Address
1221 EAST MAIN ST.
MARSHALL, MN 56258
Pharmacy Comments
Contract Details
Approval Date
10/4/2012
Contract Begin Date
10/4/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
SHARON WILLIAMS, VP OF FINANCE AND IT
(507) 537-9150
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
9/10/2012
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