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WAL-MART PHARMACY 10-0736
DSH180013 THE MEDICAL CENTER - BOWLING GREEN
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Covered Entity Details
Entity Name
THE MEDICAL CENTER - BOWLING GREEN
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180013
Entity Address
250 PARK STREET
BOWLING GREEN, KY 42101
Medicare Provider Number
180013
Participating Start Date
4/1/2005
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0736
Pharmacy Address
120 SAM WALTON DRIVE
RUSSELLVILLE, KY 42276
Pharmacy Comments
Contract Details
Approval Date
10/31/2012
Contract Begin Date
10/31/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/29/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
CONNIE SMITH, CEO
(270) 745-1262
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
10/3/2012
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