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WAL-MART PHARMACY #10-1139
DSH180018 ST CLAIRE MEDICAL CENTER INC
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Covered Entity Details
Entity Name
ST CLAIRE MEDICAL CENTER INC
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180018
Entity Address
222 MEDICAL CIRCLE
MOREHEAD, KY 40351
Medicare Provider Number
180018
Participating Start Date
1/1/2005
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY #10-1139
Pharmacy Address
200 WAL-MART WAY
MOREHEAD, KY 40351
Pharmacy Comments
Contract Details
Approval Date
1/17/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
G.R. JONES, VP FINANCIAL SERVICES/CFO
(606) 783-6508
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/16/2013
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