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WAL-MART PHARMACY 10-1388
DSH150101 WHITLEY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
WHITLEY MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH150101
Entity Address
1260 E STATE ROAD 205
COLUMBIA CITY, IN 46725-9492
Medicare Provider Number
150101
Participating Start Date
10/1/2015
Last Recertification Date
8/15/2018
Entity Termination Date
7/1/2019
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1388
Pharmacy Address
2501 E NORTH STREET
KENDALLVILLE, IN 46755
Pharmacy Comments
Contract Details
Approval Date
10/14/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/10/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Stanton Risser, Assoc Chief Financial Officer
(260) 266-9313
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
10/14/2015
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