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WAL-MART PHARMACY 10-0506
CAH141351-00 County of Clay DBA Clay County Hospital
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Covered Entity Details
Entity Name
County of Clay DBA Clay County Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH141351-00
Entity Address
911 Stacy Burk Dr.
Flora, IL 62839-3241
Medicare Provider Number
141351
Participating Start Date
10/1/2012
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0506
Pharmacy Address
1540 N WORTHY
FLORA, IL 62839
Pharmacy Comments
Contract Details
Approval Date
4/14/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/28/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jason Harris, Director of Pharmacy
(618) 662-1653
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
4/14/2016
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