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WAL-MART PHARMACY 10-1114
RRC040027-00 BAXTER REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
BAXTER REGIONAL MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC040027-00
Entity Address
624 HOSPITAL DRIVE
MOUNTAIN HOME, AR 72653
Medicare Provider Number
040027
Participating Start Date
1/1/2020
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1114
Pharmacy Address
409 SYLAMORE AVENUE
MOUNTAIN VIEW, AR 72560
Pharmacy Comments
Contract Details
Approval Date
1/15/2018
Contract Begin Date
4/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Debbie Henry, CFO
(870) 508-1003
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
1/15/2018
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