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WAL-MART PHARMACY 10-5203
DSH360189 MADISON HEALTH
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Covered Entity Details
Entity Name
MADISON HEALTH
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360189
Entity Address
210 NORTH MAIN STREET
LONDON, OH 43140
Medicare Provider Number
360189
Participating Start Date
1/1/2011
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5203
Pharmacy Address
375 LAFAYETTE ST
LONDON, OH 43140
Pharmacy Comments
Contract Details
Approval Date
10/25/2012
Contract Begin Date
10/25/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/6/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Michael S. Browning, Interim Chief Executive Officer
(740) 845-7015
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
9/7/2012
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