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WAL-MART PHARMACY 10-1309
DSH490024 CARILION MEDICAL CENTER
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Covered Entity Details
Entity Name
CARILION MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH490024
Entity Address
1906 BELLEVIEW AVE SE
ROANOKE, VA 24014
Medicare Provider Number
490024
Participating Start Date
10/1/2007
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1309
Pharmacy Address
1851 W MAIN ST
SALEM, VA 24153
Pharmacy Comments
Contract Details
Approval Date
1/16/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/21/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Tim Auwarter, VP Hospital Operations
(540) 981-7804
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/16/2020
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