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WAL-MART PHARMACY 10-2192
CAH231319-00 ASPIRUS KEWEENAW HOSPITAL
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Covered Entity Details
Entity Name
ASPIRUS KEWEENAW HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH231319-00
Entity Address
205 OSCEOLA STREET
LAURIUM, MI 49913
Medicare Provider Number
231319
Participating Start Date
1/1/2011
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2192
Pharmacy Address
995 RAZORBACK DR
HOUGHTON, MI 49931
Pharmacy Comments
Contract Details
Approval Date
8/31/2012
Contract Begin Date
9/1/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
SHANE JACQUES, Chief Financial Officer
(906) 337-6500
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
8/17/2012
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