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WAL-MART PHARMACY 10-1491
CAH161358-00 Wayne County Hospital
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Covered Entity Details
Entity Name
Wayne County Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161358-00
Entity Address
417 S East Street
Corydon, IA 50060
Medicare Provider Number
161358
Participating Start Date
4/1/2013
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1491
Pharmacy Address
1500 NORTH JEFFERSON
INDIANOLA, IA 50125
Pharmacy Comments
Contract Details
Approval Date
7/14/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/25/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Denise Hook, CFO
(641) 872-5277
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
7/14/2014
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