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WAL-MART PHARMACY 10-4278
CAH511318-00 Montgomery General Hospital, Inc
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Covered Entity Details
Entity Name
Montgomery General Hospital, Inc
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH511318-00
Entity Address
401 Sixth Avenue
Montgomery, WV 25136
Medicare Provider Number
511318
Participating Start Date
7/1/2012
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-4278
Pharmacy Address
1001 WARRIOR WAY
QUINCY, WV 25015
Pharmacy Comments
Contract Details
Approval Date
11/28/2012
Contract Begin Date
1/1/2013
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Vicki Gay, President and CEO
(304) 442-5151
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
10/11/2012
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