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WAL-MART PHARMACY 10-1519
DSH360054 HOLZER
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Covered Entity Details
Entity Name
HOLZER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360054
Entity Address
100 JACKSON PIKE
GALLIPOLIS, OH 45631
Medicare Provider Number
360054
Participating Start Date
7/1/2006
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1519
Pharmacy Address
100 WAL-MART DRIVE
JACKSON, OH 45640
Pharmacy Comments
Contract Details
Approval Date
10/10/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/28/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jerel T. Humphrey, EVP - Acute Care Services
(740) 446-5021
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
10/10/2016
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