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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
1/4/2016
Contract Begin Date
4/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Don Michael, CFO
(260) 726-7131 Ext: 1018
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
1/4/2016
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