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WAL-MART PHARMACY 10-5315
RRC360065-00 FISHER-TITUS MEDICAL CENTER
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Covered Entity Details
Entity Name
FISHER-TITUS MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC360065-00
Entity Address
272 BENEDICT AVE
NORWALK, OH 44857
Medicare Provider Number
360065
Participating Start Date
1/1/2017
Last Recertification Date
9/4/2024
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
10/5/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Brent W Burkey, MD, President
(440) 660-2550
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
10/9/2018
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