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WAL-MART PHARMACY 10-3990
DSH250069 RUSH FOUNDATION HOSPITAL
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Covered Entity Details
Entity Name
RUSH FOUNDATION HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250069
Entity Address
1314 19TH AVENUE
MERIDIAN, MS 39301
Medicare Provider Number
250069
Participating Start Date
4/1/2008
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3990
Pharmacy Address
3310-A HIGHWAY 39 NORTH
MERIDIAN, MS 39301
Pharmacy Comments
Contract Details
Approval Date
1/13/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Suzanne H Mize, 340B Administrator
(205) 459-9180
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
1/13/2022
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