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WALMART PHARMACY 10-4671
DSH440104 Erlanger Health
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Covered Entity Details
Entity Name
Erlanger Health
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH440104
Entity Address
975 East Third Street
CHATTANOOGA, TN 37403
Medicare Provider Number
440104
Participating Start Date
12/1/1992
Last Recertification Date
9/11/2024
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-4671
Pharmacy Address
4110 SHALLOWFORD RD
CHATTANOOGA, TN 37411
Pharmacy Comments
Contract Details
Approval Date
4/9/2020
Contract Begin Date
4/30/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/12/2021
Pharmacy closed
Contacts
Covered Entity Signing Official
BRITTON J. TABOR, CFO
(423) 778-7729
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
4/9/2020
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