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WAL-MART PHARMACY 10-2849
CAH361320-00 HOLZER MEDICAL CENTER-JACKSON
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Covered Entity Details
Entity Name
HOLZER MEDICAL CENTER-JACKSON
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH361320-00
Entity Address
500 BURLINGTON ROAD
JACKSON, OH 45640
Medicare Provider Number
361320
Participating Start Date
4/1/2011
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2849
Pharmacy Address
320 MALLARD LANE
MASON, WV 25260
Pharmacy Comments
Contract Details
Approval Date
1/6/2017
Contract Begin Date
4/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/26/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jerel T. Humphrey, EVP - Acute Care Services
(740) 446-5021
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
1/6/2017
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