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WAL-MART PHARMACY 10-1275
DSH150104 WITHAM MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
WITHAM MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH150104
Entity Address
2605 N. LEBANON STREET
LEBANON, IN 46052
Medicare Provider Number
150104
Participating Start Date
5/19/2020
Last Recertification Date
9/12/2022
Entity Termination Date
7/1/2023
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1275
Pharmacy Address
2440 N LEBANON
LEBANON, IN 46052
Pharmacy Comments
Contract Details
Approval Date
4/22/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
George Pogas, SR VP of Finance/CFO
(765) 485-8102
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
4/22/2014
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