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WAL-MART PHARMACY 10-4231
CAH151310-00 Parkview Wabash Hospital, Inc
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Covered Entity Details
Entity Name
Parkview Wabash Hospital, Inc
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH151310-00
Entity Address
10 John Kissinger Drive
WABASH, IN 46992-1914
Medicare Provider Number
151310
Participating Start Date
8/12/2010
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-4231
Pharmacy Address
7502 SOUTHTOWN CROSSING
FORT WAYNE, IN 46816
Pharmacy Comments
Contract Details
Approval Date
10/14/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/10/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Stanton Risser, Assoc Chief Financial Officer
(260) 266-9313
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
10/14/2015
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