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WAL-MART PHARMACY 10-0339
CAH041317-00 DALLAS COUNTY MEDICAL CENTER
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Covered Entity Details
Entity Name
DALLAS COUNTY MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH041317-00
Entity Address
201 NORTH CLIFTON ST
FORDYCE, AR 71742
Medicare Provider Number
041317
Participating Start Date
8/23/2010
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0339
Pharmacy Address
1123 HIGHWAY 79/167 BYPASS
PO BOX 705
FORDYCE, AR 71742
Pharmacy Comments
Contract Details
Approval Date
10/13/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ken Sanders, Interim Administrator
(870) 352-6363
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
10/13/2017
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