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WAL-MART PHARMACY 10-2852
DSH510013 REYNOLDS MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
REYNOLDS MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH510013
Entity Address
800 WHEELING AVENUE
GLEN DALE, WV 26038
Medicare Provider Number
510013
Participating Start Date
7/1/2021
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2852
Pharmacy Address
10 WAL-MART DRIVE
MOUNDSVILLE, WV 26041
Pharmacy Comments
Contract Details
Approval Date
10/12/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Alex Craig Inclan, CFO
(304) 843-3240
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
10/12/2021
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