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WAL-MART PHARMACY 10-1620
DSH010120 MONROE COUNTY HOSPITAL
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Covered Entity Details
Entity Name
MONROE COUNTY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH010120
Entity Address
2016 S Alabama Ave
MONROEVILLE, AL 36460
Medicare Provider Number
010120
Participating Start Date
4/1/2006
Last Recertification Date
8/16/2024
Entity Termination Date
7/1/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1620
Pharmacy Address
2578 DOUGLAS AVENUE
BREWTON, AL 36426
Pharmacy Comments
Contract Details
Approval Date
1/8/2015
Contract Begin Date
4/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/24/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jeffrey M. Brannon, CEO
(251) 743-7477
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/8/2015
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