Contract Pharmacy Details

WAL-MART PHARMACY 10-1476
DSH180040G UofL Health -- Louisville

Covered Entity Details

Entity Name

UofL Health -- Louisville

Subdivision Name

MEDICAL CENTER NORTH EAST

Type

Disproportionate Share Hospital

340B ID

DSH180040G

Entity Address

2401 TERRA CROSSING BOULEVARD
LOUISVILLE, KY 40245

Medicare Provider Number

180040

Outpatient Facility Provider Number

Participating Start Date

10/8/2009

Last Recertification Date

9/13/2020

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

340B Drug Pricing Program Database