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WAL-MART PHARMACY 10-1705
DSH330265 Clifton Springs Hospital
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Covered Entity Details
Entity Name
Clifton Springs Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330265
Entity Address
2 Coulter Road
Clifton Springs, NY 14432
Medicare Provider Number
330265
Participating Start Date
7/1/2012
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1705
Pharmacy Address
1860 NORTH ROAD
WATERLOO, NY 13165
Pharmacy Comments
Contract Details
Approval Date
10/22/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Donna Smith, VP of Operations
(315) 462-0100
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/22/2018
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