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WAL-MART PHARMACY 10-5997
CAH281304-00 Thayer County Memorial Hospital dba Thayer County Health Services
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Covered Entity Details
Entity Name
Thayer County Memorial Hospital dba Thayer County Health Services
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH281304-00
Entity Address
120 Park Avenue
Hebron, NE 68370
Medicare Provider Number
281304
Participating Start Date
4/1/2013
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5997
Pharmacy Address
9600 PARKSOUTH CT. SUITE 100
ORLANDO, FL 32837
Pharmacy Comments
Contract Details
Approval Date
1/13/2015
Contract Begin Date
4/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Michael Burcham, CEO
(402) 768-4614
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
1/13/2015
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