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WAL-MART PHARMACY 10-1113
DSH180011B SAINT JOSEPH HEALTH SYSTEM
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Covered Entity Details
Entity Name
SAINT JOSEPH HEALTH SYSTEM
Subdivision Name
Saint Joseph Hematology Oncology
Type
Disproportionate Share Hospital
340B ID
DSH180011B
Entity Address
165 London Mountain View Drive
London, KY 40741
Medicare Provider Number
180011
Outpatient Facility Provider Number
Participating Start Date
1/1/2012
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1113
Pharmacy Address
1851 WEST HWY 192
LONDON, KY 40741
Pharmacy Comments
Contract Details
Approval Date
9/7/2012
Contract Begin Date
9/7/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/12/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Robert Brock, VP Finance and Development
(253) 426-6234
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
8/24/2012
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