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WAL-MART PHARMACY 10-5315
DSH340023 ADVENTHEALTH HENDERSONVILLE
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Covered Entity Details
Entity Name
ADVENTHEALTH HENDERSONVILLE
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH340023
Entity Address
100 HOSPITAL DRIVE
HENDERSONVILLE, NC 28792
Medicare Provider Number
340023
Participating Start Date
4/1/2025
Last Recertification Date
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
10/6/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Ella Stenstrom, CFO
(828) 681-2102
Contract Pharmacy Representative
Walmart
Jodi Prohofsky, Sr Director Payer Relations
(479) 739-1973
Signed By Date
10/6/2020
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