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WAL-MART PHARMACY 10-1570
CAH361301-00 Community Memorial Hospital
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Covered Entity Details
Entity Name
Community Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH361301-00
Entity Address
208 Columbus Street
Hicksville, OH 43526
Medicare Provider Number
361301
Participating Start Date
1/1/2014
Last Recertification Date
8/31/2023
Entity Termination Date
10/1/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1570
Pharmacy Address
505 TOURING DR
AUBURN, IN 46706
Pharmacy Comments
Contract Details
Approval Date
1/4/2016
Contract Begin Date
4/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/5/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Michelle Waggoner, CEO
(419) 542-5566
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
1/4/2016
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