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WAL-MART PHARMACY 10-1729
DSH150064 FAYETTE MEMORIAL HOSPITAL ASSOCIATION
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Covered Entity Details
Entity Name
FAYETTE MEMORIAL HOSPITAL ASSOCIATION
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH150064
Entity Address
1941 VIRGINIA AVENUE
CONNERSVILLE, IN 47331
Medicare Provider Number
150064
Participating Start Date
4/1/2010
Last Recertification Date
9/4/2018
Entity Termination Date
10/1/2019
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1729
Pharmacy Address
4200 WESTERN AVENUE
CONNERSVILLE, IN 47331
Pharmacy Comments
Contract Details
Approval Date
10/26/2012
Contract Begin Date
10/26/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Skip Smith, CFO
(765) 817-7989
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
9/25/2012
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