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WAL-MART PHARMACY 10-1165
DSH180012 Baptist Health Hardin
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Covered Entity Details
Entity Name
Baptist Health Hardin
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180012
Entity Address
913 NORTH DIXIE AVENUE
ELIZABETHTOWN, KY 42701
Medicare Provider Number
180012
Participating Start Date
4/1/2017
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1165
Pharmacy Address
1165 WAL-MART WAY
RADCLIFF, KY 40160
Pharmacy Comments
Contract Details
Approval Date
4/7/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/15/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Thomas Carrico, Chief Operating Officer
(270) 706-5321
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
4/7/2019
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