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PLAZA PHARMACY
CAH181301-00 Marcum & Wallace Memorial Hospital
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Covered Entity Details
Entity Name
Marcum & Wallace Memorial Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH181301-00
Entity Address
60 Mercy Ct
Irvine, KY 40336
Medicare Provider Number
181301
Participating Start Date
7/1/2012
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
PLAZA PHARMACY
Pharmacy Address
1220 RICHMOND RD.
IRVINE, KY 40336-7232
Pharmacy Comments
Contract Details
Approval Date
10/13/2017
Contract Begin Date
1/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/14/2019
Ownership change
Contacts
Covered Entity Signing Official
Lori Witt, CFO
(606) 726-6507
Contract Pharmacy Representative
Plaza Pharmacy
James Larry Auxier, Owner
(606) 723-5315
Signed By Date
10/13/2017
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