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WAL-MART PHARMACY 10-0661
DSH010079 ATHENS-LIMESTONE
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Covered Entity Details
Entity Name
ATHENS-LIMESTONE
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH010079
Entity Address
700 WEST MARKET STREET
ATHENS, AL 35611
Medicare Provider Number
010079
Participating Start Date
3/15/2022
Last Recertification Date
9/8/2023
Entity Termination Date
1/1/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0661
Pharmacy Address
1011 U.S. HWY 72 EAST
ATHENS, AL 35611
Pharmacy Comments
Contract Details
Approval Date
4/9/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/12/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
JAMES R. COMER, CFO
(256) 233-9172
Contract Pharmacy Representative
Wal-Mart
Marcus Osbourne, Vice President
(800) 939-2022
Signed By Date
4/9/2015
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