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WALMART PHARMACY #10-569
DSH180149 TJ HEALTH COLUMBIA
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Covered Entity Details
Entity Name
TJ HEALTH COLUMBIA
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180149
Entity Address
901 Wellness Way
COLUMBIA, KY 42728
Medicare Provider Number
180149
Participating Start Date
4/1/2019
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WALMART PHARMACY #10-569
Pharmacy Address
2988 BURKESVILLE RD.
COLUMBIA, KY 42728
Pharmacy Comments
Contract Details
Approval Date
2/24/2012
Contract Begin Date
2/24/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2017
Contacts
Covered Entity Signing Official
Timothy Menton, Interim CEO
(270) 384-4753
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
2/23/2012
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