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KENTUCKY CENTRAL FILL FACILITY, L-010
CAH181301-00 Marcum & Wallace Memorial Hospital
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Covered Entity Details
Entity Name
Marcum & Wallace Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH181301-00
Entity Address
60 Mercy Ct
Irvine, KY 40336
Medicare Provider Number
181301
Participating Start Date
7/1/2012
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
KENTUCKY CENTRAL FILL FACILITY, L-010
Pharmacy Address
5594 SHEPHERDSVILLE ROAD
LOUISVILLE, KY 40228-1012
Pharmacy Comments
Contract Details
Approval Date
10/13/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/9/2022
Pharmacy closed
Contacts
Covered Entity Signing Official
Alan Archbold, Chief Financial Officer Kentucky Region
(270) 444-2553
Contract Pharmacy Representative
Kroger
Anastasia Frey, Senior Manager, Payor Contracting
(513) 698-1875
Signed By Date
10/13/2021
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