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WAL-MART PHARMACY 10-3772
DSH180050 HARLAN ARH HOSPITAL
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Covered Entity Details
Entity Name
HARLAN ARH HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180050
Entity Address
81 BALL PARK ROAD
HARLAN, KY 40831
Medicare Provider Number
180050
Participating Start Date
4/1/2005
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3772
Pharmacy Address
468 TRADE CENTER LANE
JONESVILLE, VA 24263
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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