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WAL-MART PHARMACY 10-0888
CAH261301-00 ELLETT MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
ELLETT MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH261301-00
Entity Address
610 NORTH OHIO AVENUE
Appleton City, MO 64724
Medicare Provider Number
261301
Participating Start Date
7/1/2016
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0888
Pharmacy Address
400 SOUTH FRAN
BUTLER, MO 64730
Pharmacy Comments
Contract Details
Approval Date
10/18/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/18/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Thomas C. Hollis, CEO
(660) 476-2111 Ext: 5215
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
10/18/2016
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