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WAL-MART PHARMACY 10-1634
CAH241370-00 ST. GABRIEL'S HOSPITAL
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Covered Entity Details
Entity Name
ST. GABRIEL'S HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241370-00
Entity Address
815 SE 2nd Street.
LITTLE FALLS, MN 56345
Medicare Provider Number
241370
Participating Start Date
1/1/2011
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1634
Pharmacy Address
15091 18TH ST NE
LITTLE FALLS, MN 56345
Pharmacy Comments
Contract Details
Approval Date
10/17/2012
Contract Begin Date
10/17/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
STEVEN SMITH, CFO
(320) 631-5670
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
10/15/2012
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