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WAL-MART PHARMACY 10-2078
RRC360147-00 MARIETTA MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
MARIETTA MEMORIAL HOSPITAL
Subdivision Name
Type
Rural Referral Center
340B ID
RRC360147-00
Entity Address
401 MATTHEW STREET
MARIETTA, OH 45750
Medicare Provider Number
360147
Participating Start Date
1/1/2015
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2078
Pharmacy Address
804 PIKE ST
MARIETTA, OH 45750
Pharmacy Comments
Contract Details
Approval Date
11/25/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
ERIC YOUNG, CFO
(740) 374-1641
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
11/25/2014
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