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WAL-MART PHARMACY 10-0985
CAH261306-00 SULLIVAN COUNTY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
SULLIVAN COUNTY MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH261306-00
Entity Address
630 WEST THIRD STREET
MILAN, MO 63556
Medicare Provider Number
261306
Participating Start Date
10/1/2015
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0985
Pharmacy Address
2701 W. BURLINGTON AVE.
FAIRFIELD, IA 52556
Pharmacy Comments
Contract Details
Approval Date
7/5/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jerry Dover, CEO
(660) 265-4212 Ext: 610
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
7/5/2017
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