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WAL-MART PHARMACY 10-2572
DSH360159 ADENA REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
ADENA REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360159
Entity Address
272 HOSPITAL ROAD
CHILLICOTHE, OH 45601
Medicare Provider Number
360159
Participating Start Date
4/1/2008
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2572
Pharmacy Address
990 WEST EMMITT AVENUE
WAVERLY, OH 45690
Pharmacy Comments
Contract Details
Approval Date
10/11/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Lisa Marie Carlson, CFO
(740) 779-7582
Contract Pharmacy Representative
Wal-Mart
Jodi Prohofsky, Sr. Director, Payer Relations
(254) 301-6601
Signed By Date
10/11/2019
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