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WAL-MART PHARMACY 10-0799
SCH170068-00 SOUTHWEST MEDICAL CENTER
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Covered Entity Details
Entity Name
SOUTHWEST MEDICAL CENTER
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH170068-00
Entity Address
315 W. 15th Street
LIBERAL, KS 67901
Medicare Provider Number
170068
Participating Start Date
3/15/2022
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0799
Pharmacy Address
250 EAST TUCKER ROAD
LIBERAL, KS 67901
Pharmacy Comments
Contract Details
Approval Date
1/12/2018
Contract Begin Date
3/15/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Amber Michelle Williams, CEO
(620) 629-6680
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
1/12/2018
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