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WAL-MART PHARMACY 10-3783
DSH360133AG Kettering Health Dayton
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Covered Entity Details
Entity Name
Kettering Health Dayton
Subdivision Name
Operating Room 50.00 / Pain Center 384030
Type
Disproportionate Share Hospital
340B ID
DSH360133AG
Entity Address
425 W. Grand Ave.
Suite 1006
DAYTON, OH 45405
Medicare Provider Number
360133
Outpatient Facility Provider Number
Participating Start Date
7/1/2018
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3783
Pharmacy Address
3465 YORK COMMONS BOULEVARD
DAYTON, OH 45414
Pharmacy Comments
Contract Details
Approval Date
5/9/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/5/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Luis Chanaga, CFO
(937) 723-3414
Contract Pharmacy Representative
Kettering Health Network:Grandview/Kettering/Ft Hamilton/Sycamore/Soin
Linda McCall, Pharmacy Director
(937) 458-4946
Signed By Date
4/13/2018
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