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WAL-MART PHARMACY 10-2388
CAH151320-00 JAY COUNTY HOSPITAL
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Covered Entity Details
Entity Name
JAY COUNTY HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH151320-00
Entity Address
500 W. VOTAW
PORTLAND, IN 47371
Medicare Provider Number
151320
Participating Start Date
1/1/2016
Last Recertification Date
11/3/2017
Entity Termination Date
4/1/2018
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2388
Pharmacy Address
950 W VOTAW
PORTLAND, IN 47371
Pharmacy Comments
Contract Details
Approval Date
7/16/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2015
Contacts
Covered Entity Signing Official
Don Michael, CFO
(260) 726-7131 Ext: 1018
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
7/16/2015
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