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WAL-MART PHARMACY 10-2159
DSH330096 JONES MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
JONES MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330096
Entity Address
191 North Main Street
WELLSVILLE, NY 14895-0072
Medicare Provider Number
330096
Participating Start Date
10/1/2017
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2159
Pharmacy Address
RTE 417
1869 PLAZA DR
OLEAN, NY 14760
Pharmacy Comments
Contract Details
Approval Date
10/3/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/28/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
James Helms, Vice President of Finance
(585) 596-4002
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
10/3/2018
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