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WAL-MART PHARMACY 10-0348
CAH041328-00 Chicot Memorial Medical Center
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Covered Entity Details
Entity Name
Chicot Memorial Medical Center
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH041328-00
Entity Address
Chicot Memorial Medical Center
2729 S. Hwy 65 & 82
Lake Village, AR 71653
Medicare Provider Number
041328
Participating Start Date
4/17/2017
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0348
Pharmacy Address
427 HWY 425 NORTH
MONTICELLO, AR 71655
Pharmacy Comments
Contract Details
Approval Date
4/17/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
David Mantz, CEO
(870) 265-5351 Ext: 396
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
4/17/2017
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