Contract Pharmacy Details

WAL-MART PHARMACY 10-1234
CAH181321-00 Wayne County Hospital, Inc.

Covered Entity Details

Entity Name

Wayne County Hospital, Inc.

Subdivision Name

Type

Critical Access Hospital

340B ID

CAH181321-00

Entity Address

166 Hospital Street
Monticello, KY 42633

Medicare Provider Number

181321

Participating Start Date

4/1/2012

Last Recertification Date

8/21/2024

Pharmacy Details

Pharmacy Name

WAL-MART PHARMACY 10-1234

Pharmacy Address

175 WAL-MART PLAZA DRIVE
MONTICELLO, KY 42633

Pharmacy Comments

Contract Details

Approval Date

8/29/2012

Contract Begin Date

8/29/2012

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

12/9/2016
Business decision by covered entity and/or pharmacy

Contacts

Covered Entity Signing Official

Anne Sawyer, CFO
(606) 348-9343

Contract Pharmacy Representative

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

Signed By Date

8/22/2012

340B Drug Pricing Program Database