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WAL-MART PHARMACY 10-0696
DSH180005 HIGHLANDS ARH REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
HIGHLANDS ARH REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180005
Entity Address
5000 KY RT 321
PRESTONSBURG, KY 41653
Medicare Provider Number
180005
Participating Start Date
9/9/2005
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0696
Pharmacy Address
477 VILLAGE DRIVE
PRESTONBURG, KY 41653
Pharmacy Comments
Contract Details
Approval Date
5/15/2012
Contract Begin Date
5/24/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Bud Warman, CEO
(606) 886-8511
Contract Pharmacy Representative
Wal--Mart
Marcus Osborne, Sales & Contracting
(479) 204-8452
Signed By Date
5/18/2012
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