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WAL-MART PHARMACY 10-1778
CAH531310-00 Powell Valley Healthcare
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Covered Entity Details
Entity Name
Powell Valley Healthcare
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH531310-00
Entity Address
777 Ave H
Powell, WY 82435
Medicare Provider Number
531310
Participating Start Date
1/1/2012
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1778
Pharmacy Address
321 YELLOWSTONE AVENUE
CODY, WY 82414
Pharmacy Comments
Contract Details
Approval Date
7/2/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Bill Patten, CEO
(307) 754-1101
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
7/2/2014
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