Contract Pharmacy Details

WALMART PHARMACY #10-2260
RRC010005-00 MARSHALL MEDICAL CENTER SOUTH

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

WALMART PHARMACY #10-2260

Pharmacy Address

87395 US HWY 278
SNEAD, AL 35952

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

1/29/2016
Pharmacy closed

Contacts

Covered Entity Signing Official

GARY R. GORE, CEO
(256) 894-6611

Contract Pharmacy Representative

Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374

Signed By Date

4/6/2015

340B Drug Pricing Program Database