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WALMART PHARMACY 10-2931
DSH210019 TIDALHEALTH PENINSULA REGIONAL INC
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Covered Entity Details
Entity Name
TIDALHEALTH PENINSULA REGIONAL INC
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH210019
Entity Address
100 EAST CARROLL STREET
SALISBURY, MD 21801
Medicare Provider Number
210019
Participating Start Date
3/15/2022
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-2931
Pharmacy Address
409 N FRUITLAND BLVD
FRUITLAND, MD 21801
Pharmacy Comments
Contract Details
Approval Date
10/9/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/2/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Bruce Ritchie, CFO
(410) 543-7298
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/9/2018
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