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COMMCARE PHARMACY-FTL, LLC
CAH181301-00 Marcum & Wallace Memorial Hospital
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Covered Entity Details
Entity Name
Marcum & Wallace Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH181301-00
Entity Address
60 Mercy Ct
Irvine, KY 40336
Medicare Provider Number
181301
Participating Start Date
7/1/2012
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
COMMCARE PHARMACY-FTL, LLC
Pharmacy Address
855 SW 78TH AVE STE C100
PLANTATION, FL 33324-3223
Pharmacy Comments
Contract Details
Approval Date
4/15/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Lori Witt, CFO
(606) 726-6507
Contract Pharmacy Representative
Commcare Specialty Pharmacy
Bob Raffalo, VP Operations
(954) 284-2384
Signed By Date
4/15/2019
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