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WAL-MART PHARMACY 10-2102
CAH231320-00 Trinity Health Shelby Hospital
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Covered Entity Details
Entity Name
Trinity Health Shelby Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH231320-00
Entity Address
72 SOUTH STATE STREET
SHELBY, MI 49455
Medicare Provider Number
231320
Participating Start Date
8/9/2010
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2102
Pharmacy Address
4854 WEST U.S. HWY 10
LUDINGTON, MI 49431
Pharmacy Comments
Contract Details
Approval Date
4/10/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
JAY BRYAN, PRESIDENT
(231) 861-3030
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/10/2018
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