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WAL-MART PHARMACY 10-2607
CAH271343-00 Providence Saint Joseph Medical Center
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Covered Entity Details
Entity Name
Providence Saint Joseph Medical Center
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH271343-00
Entity Address
6-13th AVENUE EAST
POLSON, MT 59860
Medicare Provider Number
271343
Participating Start Date
10/1/2011
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2607
Pharmacy Address
36318 MEMORY LANE
POLSON, MT 59860
Pharmacy Comments
Contract Details
Approval Date
3/8/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
James Kiser, Chief Executive Officer
(406) 883-8416
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/15/2013
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