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WALMART PHARMACY 10-5169
DSH440059 COOKEVILLE REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
COOKEVILLE REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH440059
Entity Address
Cookeville Regional Medical Center
1 Medical Center Blvd
COOKEVILLE, TN 38501
Medicare Provider Number
440059
Participating Start Date
4/1/2023
Last Recertification Date
8/22/2024
Entity Termination Date
1/1/2025
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-5169
Pharmacy Address
2252 NORTH 8TH STREET
SUITE A
ROGERS, AR 72756
Pharmacy Comments
Contract Details
Approval Date
2/14/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/4/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
PAUL Dudley KORTH, CEO
(931) 783-2000
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
1/16/2023
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