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WAL-MART PHARMACY 10-5315
RRC440059-00 COOKEVILLE REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
COOKEVILLE REGIONAL MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC440059-00
Entity Address
142 WEST FIFTH STREET
COOKEVILLE, TN 38501
Medicare Provider Number
440059
Participating Start Date
4/1/2025
Last Recertification Date
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
7/15/2019
Contract Begin Date
3/15/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
PAUL Dudley KORTH, CEO
(931) 783-2000
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
7/15/2019
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