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WAL-MART PHARMACY 10-2610
CAH511313-00 BOONE MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
BOONE MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH511313-00
Entity Address
701 Madison Avenue
MADISON, WV 25130
Medicare Provider Number
511313
Participating Start Date
1/1/2011
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2610
Pharmacy Address
77 NORMAN MORGAN BLVD
LOGAN, WV 25601
Pharmacy Comments
Contract Details
Approval Date
4/28/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Virgil Lee Underwood, CEO
(304) 369-1230 Ext: 5507
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
4/28/2020
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