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WAL-MART PHARMACY 10-0884
DSH150097 MAJOR HOSPITAL
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Covered Entity Details
Entity Name
MAJOR HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH150097
Entity Address
2451 INTELLIPLEX DR
SHELBYVILLE, IN 46176
Medicare Provider Number
150097
Participating Start Date
7/1/2022
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0884
Pharmacy Address
2500 PROGRESS PKWY
SHELBYVILLE, IN 46176
Pharmacy Comments
Contract Details
Approval Date
7/12/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ralph N Mercuri, CFO
(317) 398-5254
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
7/12/2022
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