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WAL-MART PHARMACY 10-0020
RRC260175-00 GOLDEN VALLEY MEMORIAL HOSPITAL DISTRICT
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Covered Entity Details
Entity Name
GOLDEN VALLEY MEMORIAL HOSPITAL DISTRICT
Subdivision Name
Type
Rural Referral Center
340B ID
RRC260175-00
Entity Address
1600 NORTH SECOND STREET
CLINTON, MO 64735
Medicare Provider Number
260175
Participating Start Date
9/29/2010
Last Recertification Date
8/31/2020
Entity Termination Date
10/1/2021
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0020
Pharmacy Address
1712 EAST OHIO
CLINTON, MO 64735
Pharmacy Comments
Contract Details
Approval Date
10/13/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Mark Mattes, CNO
(660) 890-7167
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
10/13/2014
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