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WAL-MART PHARMACY #10-0694
DSH180056 Deaconess Henderson Hospital
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Covered Entity Details
Entity Name
Deaconess Henderson Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH180056
Entity Address
1305 NORTH ELM STREET
HENDERSON, KY 42420
Medicare Provider Number
180056
Participating Start Date
1/1/2009
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY #10-0694
Pharmacy Address
1195 BARRETT BLVD
HENDERSON, KY 42420
Pharmacy Comments
Contract Details
Approval Date
7/22/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/31/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
BRUCE BEGLEY, CEO
(270) 827-7700
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
7/22/2014
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