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WAL-MART PHARMACY 10-0205
DSH250069 RUSH FOUNDATION HOSPITAL
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Covered Entity Details
Entity Name
RUSH FOUNDATION HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH250069
Entity Address
1314 19TH AVENUE
MERIDIAN, MS 39301
Medicare Provider Number
250069
Participating Start Date
4/1/2008
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0205
Pharmacy Address
1002 BEACON ST
PHILADELPHIA, MS 39350
Pharmacy Comments
Contract Details
Approval Date
7/23/2012
Contract Begin Date
7/23/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Larkin Kennedy, VP of Hospital Division
(601) 703-1317
Contract Pharmacy Representative
Wal--Mart
Marcus Osborne, Sales & Contracting
(479) 204-8452
Signed By Date
6/29/2012
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