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WAL-MART PHARMACY 10-0342
CAH171341-00 Hiawatha Hospital Association, Inc
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Covered Entity Details
Entity Name
Hiawatha Hospital Association, Inc
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH171341-00
Entity Address
300 UTAH ST.
HIAWATHA, KS 66434-2399
Medicare Provider Number
171341
Participating Start Date
4/1/2011
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0342
Pharmacy Address
701 HOPI DR.
HIAWATHA, KS 66434
Pharmacy Comments
Contract Details
Approval Date
4/2/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
JOHN MOORE, CEO/ADMINISTRATOR
(785) 742-2131 Ext: 283
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
4/2/2015
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