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WAL-MART PHARMACY 10-2477
RRC380027-00 MERCY MEDICAL CENTER
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Covered Entity Details
Entity Name
MERCY MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC380027-00
Entity Address
2700 NW STEWART PARKWAY
ROSEBURG, OR 97471
Medicare Provider Number
380027
Participating Start Date
7/1/2011
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2477
Pharmacy Address
2125 NW STEWART PKWY
ROSEBURG, OR 97471
Pharmacy Comments
Contract Details
Approval Date
11/5/2012
Contract Begin Date
11/5/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/27/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
John Kasberger, CFO/CRO
(541) 677-2458
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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