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WALMART PHARMACY #10-7266
RRC150082-00 DEACONESS HOSPITAL
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Covered Entity Details
Entity Name
DEACONESS HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC150082-00
Entity Address
600 MARY STREET
EVANSVILLE, IN 47747
Medicare Provider Number
150082
Participating Start Date
10/20/2021
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
WALMART PHARMACY #10-7266
Pharmacy Address
4924 S. MAPLE TREE DRIVE
PRINCETON, IN 47670
Pharmacy Comments
Contract Details
Approval Date
10/20/2021
Contract Begin Date
10/20/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Cheryl Wathen, Chief Financial Officer
(812) 450-3296
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/12/2021
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