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WAL-MART PHARMACY 10-5315
DSH180095 CRITTENDEN COUNTY HOSPITAL INC.
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Covered Entity Details
Entity Name
CRITTENDEN COUNTY HOSPITAL INC.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180095
Entity Address
520 W Gum St
MARION, KY 42064
Medicare Provider Number
180095
Participating Start Date
7/1/2018
Last Recertification Date
8/17/2018
Entity Termination Date
1/1/2019
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
7/17/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Daniel John Hiben, Chief Executive Officer
(270) 965-1018
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
7/17/2018
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