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WAL-MART PHARMACY 10-1476
DSH180040B UofL Health -- Louisville
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Covered Entity Details
Entity Name
UofL Health -- Louisville
Subdivision Name
MARY & ELIZABETH HOSPITAL
Type
Disproportionate Share Hospital
340B ID
DSH180040B
Entity Address
1850 BLUEGRASS AVE
LOUISVILLE, KY 40215
Medicare Provider Number
180040
Outpatient Facility Provider Number
Participating Start Date
7/1/2004
Last Recertification Date
9/13/2020
Entity Termination Date
4/1/2021
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1476
Pharmacy Address
1351 VETERANS PKWY
CLARKSVILLE, IN 47129
Pharmacy Comments
Contract Details
Approval Date
9/24/2012
Contract Begin Date
9/24/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/15/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Ronald Farr, CFO, Sr. VP
(502) 540-3888
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
9/21/2012
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