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WAL-MART PHARMACY 10-1476
DSH180040C UofL Health -- Louisville
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Covered Entity Details
Entity Name
UofL Health -- Louisville
Subdivision Name
Peace Hospital
Type
Disproportionate Share Hospital
340B ID
DSH180040C
Entity Address
2020 NEWBURG ROAD
LOUISVILLE, KY 40205
Medicare Provider Number
180040
Outpatient Facility Provider Number
Participating Start Date
7/1/2005
Last Recertification Date
9/14/2020
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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