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WAL-MART PHARMACY 10-0065
CAH261337-00 Missouri Baptist Hospital of Sullivan, DBA, Missouri Baptist Sullivan Hospital
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Covered Entity Details
Entity Name
Missouri Baptist Hospital of Sullivan, DBA, Missouri Baptist Sullivan Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH261337-00
Entity Address
751 Sappington Bridge Road
Sullivan, MO 63080
Medicare Provider Number
261337
Participating Start Date
1/1/2013
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0065
Pharmacy Address
350 PARK RIDGE RD
SULLIVAN, MO 63080
Pharmacy Comments
Contract Details
Approval Date
4/14/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/1/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Tony L. Schwarm, President
(573) 468-1343 Ext: 1343
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
4/14/2014
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