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WAL-MART PHARMACY 10-1743
DSH180020 MIDDLESBORO ARH HOSPITAL
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Covered Entity Details
Entity Name
MIDDLESBORO ARH HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180020
Entity Address
3600 WEST CUMBERLAND AVE
MIDDLESBORO, KY 40965
Medicare Provider Number
180020
Participating Start Date
4/1/2005
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1743
Pharmacy Address
201 WALTON ROAD
HARLAN, KY 40831
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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