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WAL-MART PHARMACY 10-0825
CAH181315-00 FORT LOGAN HOSPITAL
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Covered Entity Details
Entity Name
FORT LOGAN HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH181315-00
Entity Address
110 METKER TRAIL
STANFORD, KY 40484
Medicare Provider Number
181315
Participating Start Date
9/16/2010
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0825
Pharmacy Address
1283 US HIGHWAY 27 NORTH
STANFORD, KY 40484
Pharmacy Comments
Contract Details
Approval Date
10/6/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
INA GLASS, INTERIM ADMINISTRATOR
(606) 365-4600
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
10/6/2016
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