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WAL-MART PHARMACY 10-2610
DSH180069 TUG VALLEY ARH REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
TUG VALLEY ARH REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180069
Entity Address
260 HOSPITAL DRIVE
SOUTH WILLIAMSON, KY 41503
Medicare Provider Number
180069
Participating Start Date
4/1/2005
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2610
Pharmacy Address
77 NORMAN MORGAN BLVD
LOGAN, WV 25601
Pharmacy Comments
Contract Details
Approval Date
10/9/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Maria Braman, Chief Medical Officer
(406) 465-8506
Contract Pharmacy Representative
Walmart
Van Donn, Director of Contracting 340b
(303) 261-5549
Signed By Date
10/9/2023
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