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WAL-MART PHARMACY 10-0696
CAH181305-00 ARH OUR LADY OF THE WAY
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Covered Entity Details
Entity Name
ARH OUR LADY OF THE WAY
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH181305-00
Entity Address
11203 MAIN STREET
MARTIN, KY 41649
Medicare Provider Number
181305
Participating Start Date
9/24/2010
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0696
Pharmacy Address
477 VILLAGE DRIVE
PRESTONBURG, KY 41653
Pharmacy Comments
Contract Details
Approval Date
10/18/2012
Contract Begin Date
10/18/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/30/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kathy Stumbo, CEO
(606) 285-6401
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
10/15/2012
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