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WAL-MART PHARMACY 10-5104
DSH360133 Kettering Health Dayton
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Covered Entity Details
Entity Name
Kettering Health Dayton
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360133
Entity Address
405 W. Grand Avenue
Dayton, OH 45405
Medicare Provider Number
360133
Participating Start Date
7/1/2013
Last Recertification Date
8/22/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5104
Pharmacy Address
1701 W DOROTHY LN
MORAINE, OH 45439
Pharmacy Comments
Contract Details
Approval Date
4/12/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/28/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
William E Villegas, Regional VP of Finance
(937) 723-3414
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
4/12/2021
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