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Walmart Pharmacy 10-7611
DSH010164 COOSA VALLEY MEDICAL CENTER
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Covered Entity Details
Entity Name
COOSA VALLEY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH010164
Entity Address
315 W. HICKORY STREET
SYLACAUGA, AL 35150
Medicare Provider Number
010164
Participating Start Date
12/1/2005
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
Walmart Pharmacy 10-7611
Pharmacy Address
2501 Perry Rd
Plainfield, IN 46168
Pharmacy Comments
Contract Details
Approval Date
10/13/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brad McCormick, CFO
(256) 401-4534
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
10/13/2023
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