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WAL-MART PHARMACY 10-0454
CAH141311-00 FAIRFIELD MEMORIAL HOSPITAL ASSOCIATION
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Covered Entity Details
Entity Name
FAIRFIELD MEMORIAL HOSPITAL ASSOCIATION
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH141311-00
Entity Address
303 NW 11TH STREET
FAIRFIELD, IL 62837
Medicare Provider Number
141311
Participating Start Date
7/1/2011
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0454
Pharmacy Address
150 COMMERCE DR.
FAIRFIELD, IL 62837
Pharmacy Comments
Contract Details
Approval Date
7/16/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kathy Clayton, CHIEF FINANCIAL OFFICER
(618) 847-8260
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
7/16/2014
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