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WAL-MART PHARMACY 10-1113
DSH180043 AdventHealth Manchester
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Covered Entity Details
Entity Name
AdventHealth Manchester
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180043
Entity Address
210 MARIE LANGDON DRIVE
MANCHESTER, KY 40962
Medicare Provider Number
180043
Participating Start Date
10/1/2017
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1113
Pharmacy Address
1851 WEST HWY 192
LONDON, KY 40741
Pharmacy Comments
Contract Details
Approval Date
4/15/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
STEVEN MILLER, VP FINANCE/CFO
(606) 598-1035
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/15/2019
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