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WAL-MART PHARMACY 10-5315
DSH230015 THREE RIVERS HEALTH
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Covered Entity Details
Entity Name
THREE RIVERS HEALTH
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH230015
Entity Address
701 S. HEALTH PARKWAY
THREE RIVERS, MI 49093
Medicare Provider Number
230015
Participating Start Date
10/1/2011
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
10/9/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/10/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
STEVEN T. ANDREWS, CFO
(269) 273-9604
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
10/9/2018
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