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WALMART PHARMACY #10-569
CAH181330-00 RUSSELL COUNTY HOSPITAL
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Covered Entity Details
Entity Name
RUSSELL COUNTY HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH181330-00
Entity Address
153 DOWELL ROAD
RUSSELL SPRINGS, KY 42642
Medicare Provider Number
181330
Participating Start Date
7/1/2011
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WALMART PHARMACY #10-569
Pharmacy Address
2988 BURKESVILLE RD.
COLUMBIA, KY 42728
Pharmacy Comments
Contract Details
Approval Date
1/6/2015
Contract Begin Date
4/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/13/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Barry Corbin, Director of Professional Services
(270) 634-3195
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
1/6/2015
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