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WAL-MART PHARMACY 10-5410
RRC360084-00 AULTMAN HOSPITAL
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Covered Entity Details
Entity Name
AULTMAN HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC360084-00
Entity Address
2600 SIXTH STREET SW
CANTON, OH 44710
Medicare Provider Number
360084
Participating Start Date
7/1/2017
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5410
Pharmacy Address
4004 TUSCARANAS STREET WEST
CANTON (C), OH 44708
Pharmacy Comments
Contract Details
Approval Date
7/15/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/21/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Adam M Luntz, CHIEF FINANCIAL OFFICER
(330) 363-3889 Ext: 0
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
7/15/2022
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