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WAL-MART PHARMACY 10-5997
RRC010005-00 MARSHALL MEDICAL CENTER SOUTH
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Covered Entity Details
Entity Name
MARSHALL MEDICAL CENTER SOUTH
Subdivision Name
Type
Rural Referral Center
340B ID
RRC010005-00
Entity Address
2505 US HIGHWAY 431 NORTH
BOAZ, AL 35957
Medicare Provider Number
010005
Participating Start Date
7/1/2011
Last Recertification Date
8/5/2015
Entity Termination Date
4/1/2016
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5997
Pharmacy Address
9600 PARKSOUTH CT. SUITE 100
ORLANDO, FL 32837
Pharmacy Comments
Contract Details
Approval Date
4/6/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2016
Covered Entity Terminated
Contacts
Covered Entity Signing Official
GARY R. GORE, CEO
(256) 894-6611
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
4/6/2015
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