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WAL-MART PHARMACY 10-5309
RRC360065-00 FISHER-TITUS MEDICAL CENTER
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Covered Entity Details
Entity Name
FISHER-TITUS MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC360065-00
Entity Address
272 BENEDICT AVE
NORWALK, OH 44857
Medicare Provider Number
360065
Participating Start Date
1/1/2017
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5309
Pharmacy Address
46440 US ROUTE 20
OBERLIN, OH 44074
Pharmacy Comments
Contract Details
Approval Date
10/12/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/5/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Brent W Burkey, MD, President
(440) 660-2550
Contract Pharmacy Representative
Walmart
Craig Smith, RPh.
(479) 903-5739
Signed By Date
10/12/2020
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