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WAL-MART PHARMACY 10-0696
CAH181305-00 ARH OUR LADY OF THE WAY
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Covered Entity Details
Entity Name
ARH OUR LADY OF THE WAY
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH181305-00
Entity Address
11203 MAIN STREET
MARTIN, KY 41649
Medicare Provider Number
181305
Participating Start Date
9/24/2010
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0696
Pharmacy Address
477 VILLAGE DRIVE
PRESTONBURG, KY 41653
Pharmacy Comments
Contract Details
Approval Date
7/12/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Joseph Grossman, PRESIDENT and CEO
(859) 226-2450
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
7/12/2019
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