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WAL-MART PHARMACY 10-2654
SCH180105-00 MONROE COUNTY MEDICAL CENTER
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Covered Entity Details
Entity Name
MONROE COUNTY MEDICAL CENTER
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH180105-00
Entity Address
529 CAPP HARLAN ROAD
TOMPKINSVILLE, KY 42167
Medicare Provider Number
180105
Participating Start Date
7/1/2018
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2654
Pharmacy Address
1650 EDMONTON ROAD
TOMPKINSVILLE, KY 42167
Pharmacy Comments
Contract Details
Approval Date
10/14/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/16/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Polly Baker, Chairman of Board
(270) 487-9231
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
10/14/2021
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