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WAL-MART PHARMACY 10-1152
CAH161346-00 SIOUX CENTER HEALTH
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Covered Entity Details
Entity Name
SIOUX CENTER HEALTH
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161346-00
Entity Address
1101 9th St SE
SIOUX CENTER, IA 51250-1398
Medicare Provider Number
161346
Participating Start Date
9/28/2010
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1152
Pharmacy Address
WAL-MART STORES, INC
255 16TH ST SW
SIOUX CENTER, IA 51250
Pharmacy Comments
Contract Details
Approval Date
10/11/2012
Contract Begin Date
10/11/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
KAYLEEN LEE, CHIEF EXECUTIVE OFFICER
(712) 722-8107
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
9/11/2012
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