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WAL-MART PHARMACY 10-1036
DSH340075 Blue Ridge HealthCare Hospitals, Inc
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Covered Entity Details
Entity Name
Blue Ridge HealthCare Hospitals, Inc
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH340075
Entity Address
2201 SOUTH STERLING STREET
MORGANTON, NC 28655
Medicare Provider Number
340075
Participating Start Date
12/6/2005
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1036
Pharmacy Address
197 PLAZA DRIVE
FOREST CITY, NC 28043
Pharmacy Comments
Contract Details
Approval Date
1/8/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/1/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
KATHY BAILEY, CEO
(828) 580-5586
Contract Pharmacy Representative
Wal-Mart
Jodi Prohofsky, Sr. Director, Payer Relations
(254) 301-6601
Signed By Date
1/8/2019
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