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WAL-MART PHARMACY 10-1539
CAH361316-03 BUCYRUS COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
BUCYRUS COMMUNITY HOSPITAL
Subdivision Name
Provider Based Clinic - (PBC 629)
Type
Critical Access Hospital
340B ID
CAH361316-03
Entity Address
629 North Sandusky Avenue
Bucyrus, OH 44820
Medicare Provider Number
361316
Outpatient Facility Provider Number
Participating Start Date
10/1/2018
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1539
Pharmacy Address
359 LEXINGTON SPRINGMILL
MANSFIELD, OH 44906
Pharmacy Comments
Contract Details
Approval Date
7/13/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/1/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Eric Draime, CFO
(419) 468-0501
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
7/13/2022
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