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WAL-MART CENTRAL FILL 10-2670
CAH241325-00 CCM Health
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Covered Entity Details
Entity Name
CCM Health
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH241325-00
Entity Address
824 N 11Th St
Montevideo, MN 56265
Medicare Provider Number
241325
Participating Start Date
1/1/2012
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
WAL-MART CENTRAL FILL 10-2670
Pharmacy Address
608 SPRING HILL DR # 3 SUITE 300
SPRING, TX 77386
Pharmacy Comments
Contract Details
Approval Date
7/17/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Mark E. Paulson, Administrator
(320) 321-8100
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
7/17/2014
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