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WAL-MART PHARMACY 10-4272
DSH460015 LOGAN REGIONAL HOSPITAL
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Covered Entity Details
Entity Name
LOGAN REGIONAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH460015
Entity Address
1400 NORTH 500 EAST
LOGAN, UT 84341
Medicare Provider Number
460015
Participating Start Date
7/1/2011
Last Recertification Date
8/22/2018
Entity Termination Date
7/1/2019
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-4272
Pharmacy Address
1150 S 100 W
LOGAN, UT 84321
Pharmacy Comments
Contract Details
Approval Date
1/15/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Justin Wiser, Finance Director
(435) 716-5331
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/15/2019
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