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WAL-MART PHARMACY 10-0095
CAH261302-00 MADISON MEDICAL CENTER
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Covered Entity Details
Entity Name
MADISON MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH261302-00
Entity Address
611 WEST MAIN STREET
FREDERICKTOWN, MO 63645
Medicare Provider Number
261302
Participating Start Date
12/9/2011
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0095
Pharmacy Address
407 N. STATE ST
DESLOGE, MO 63601
Pharmacy Comments
Contract Details
Approval Date
10/16/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/3/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Lisa Twidwell, CEO
(573) 783-1020 Ext: 3311
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
10/16/2013
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