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WAL-MART PHARMACY 10-1707
RRC510023-00 WEIRTON MEDICAL CENTER
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Covered Entity Details
Entity Name
WEIRTON MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC510023-00
Entity Address
601 COLLIERS WAY
WEIRTON, WV 26062
Medicare Provider Number
510023
Participating Start Date
1/1/2021
Last Recertification Date
8/31/2021
Entity Termination Date
1/1/2022
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1707
Pharmacy Address
16280 DRESDEN DR
EAST LIVERPOOL, OH 43920
Pharmacy Comments
Contract Details
Approval Date
12/1/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/30/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Eugene D Trout, CFO
(304) 797-6323
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/15/2020
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