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WAL-MART PHARMACY 10-2149
SCH360040-00 KNOX COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
KNOX COMMUNITY HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH360040-00
Entity Address
1330 COSHOCTON AVE
MOUNT VERNON, OH 43050
Medicare Provider Number
360040
Participating Start Date
10/1/2014
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2149
Pharmacy Address
1575 COSHOCTON AVE
MT VERNON, OH 43050
Pharmacy Comments
Contract Details
Approval Date
7/3/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
MICHAEL AMBROSIANI, CHIEF FINANCIAL OFFICER
(740) 393-9623
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
7/3/2015
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