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WAL-MART PHARMACY 10-1707
DSH360096 EAST LIVERPOOL CITY HOSPITAL
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Covered Entity Details
Entity Name
EAST LIVERPOOL CITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360096
Entity Address
425 WEST FIFTH STREET
EAST LIVERPOOL, OH 43920
Medicare Provider Number
360096
Participating Start Date
7/1/2015
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1707
Pharmacy Address
16280 DRESDEN DR
EAST LIVERPOOL, OH 43920
Pharmacy Comments
Contract Details
Approval Date
7/15/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Keith Richardson, CEO
(330) 386-2002
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
7/15/2020
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