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WAL-MART PHARMACY 10-1621
CAH161342-00 Monroe County Hospital
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Covered Entity Details
Entity Name
Monroe County Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161342-00
Entity Address
6580 165th Street
Albia, IA 52531
Medicare Provider Number
161342
Participating Start Date
1/1/2013
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1621
Pharmacy Address
23148 HWY 5
CENTERVILLE, IA 52544
Pharmacy Comments
Contract Details
Approval Date
4/2/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/5/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jenny Klyn, Chief Ancillary Officer
(641) 932-1720
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
4/2/2014
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