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WAL-MART PHARMACY 10-3610
DSH180040D UofL Health -- Louisville
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Covered Entity Details
Entity Name
UofL Health -- Louisville
Subdivision Name
DBA ST MARY'S SURGERY CENTER
Type
Disproportionate Share Hospital
340B ID
DSH180040D
Entity Address
1850 Bluegrass Ave
LOUISVILLE, KY 40215
Medicare Provider Number
180040
Outpatient Facility Provider Number
Participating Start Date
7/1/2005
Last Recertification Date
8/31/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3610
Pharmacy Address
7100 RAGGARD ROAD
LOUISVILLE, KY 40216-1254
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
5/10/2016
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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