Contract Pharmacy Details

WAL-MART PHARMACY 10-1476
DSH180040A JEWISH HOSPITAL AND ST MARY'S HEALTHCARE (JHSMH)

Covered Entity Details

Entity Name

JEWISH HOSPITAL AND ST MARY'S HEALTHCARE (JHSMH)

Subdivision Name

DBA Amerimed1

Type

Disproportionate Share Hospital

340B ID

DSH180040A

Entity Address

5111 COMMERCE CROSSING DRIVE
SUITE 130
LOUISVILLE, KY 40229

Medicare Provider Number

180040

Outpatient Facility Provider Number

Participating Start Date

12/15/2005

Last Recertification Date

11/13/2017

Entity Termination Date

4/1/2018

Pharmacy Details

Pharmacy Name

WAL-MART PHARMACY 10-1476

Pharmacy Address

1351 VETERANS PKWY
CLARKSVILLE, IN 47129

Pharmacy Comments

Contract Details

Approval Date

9/24/2012

Contract Begin Date

9/24/2012

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

6/15/2016
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Ronald Farr, CFO, Sr. VP
(502) 540-3888

Contract Pharmacy Representative

Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374

Signed By Date

9/21/2012

340B Drug Pricing Program Database