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WALMART PHARMACY 10-5169
RRC440059-00 COOKEVILLE REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
COOKEVILLE REGIONAL MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC440059-00
Entity Address
142 WEST FIFTH STREET
COOKEVILLE, TN 38501
Medicare Provider Number
440059
Participating Start Date
4/1/2025
Last Recertification Date
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
1/16/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2023
Covered Entity Terminated
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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