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WAL-MART PHARMACY 10-0203
CAH261307-00 GENERAL JOHN J. PERSHING MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
GENERAL JOHN J. PERSHING MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH261307-00
Entity Address
130 E. LOCKLING AVENUE
BROOKFIELD, MO 64628
Medicare Provider Number
261307
Participating Start Date
4/1/2011
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0203
Pharmacy Address
937 PARK CIRCLE DRIVE
PO BOX 158
BROOKFIELD, MO 64628
Pharmacy Comments
Contract Details
Approval Date
2/11/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
PHIL HAMILTON, CEO
(660) 258-1148
Contract Pharmacy Representative
Marcus Osborne, VP of Health & Wellness Sales and Contracting
(479) 204-9374
Signed By Date
1/3/2013
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