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WAL-MART PHARMACY 10-3783
DSH360133 Kettering Health Dayton
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Covered Entity Details
Entity Name
Kettering Health Dayton
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360133
Entity Address
405 W. Grand Avenue
Dayton, OH 45405
Medicare Provider Number
360133
Participating Start Date
7/1/2013
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3783
Pharmacy Address
3465 YORK COMMONS BOULEVARD
DAYTON, OH 45414
Pharmacy Comments
Contract Details
Approval Date
4/27/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/25/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Luis Chanaga, CFO
(937) 723-3414
Contract Pharmacy Representative
Kettering Health Network:Grandview/Kettering/Ft Hamilton/Sycamore/Soin
Linda McCall, Pharmacy Director
(937) 458-4946
Signed By Date
4/27/2018
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