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WAL-MART PHARMACY 10-3804
DSH210040 NORTHWEST HOSPITAL CENTER, INC.
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Covered Entity Details
Entity Name
NORTHWEST HOSPITAL CENTER, INC.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH210040
Entity Address
5401 OLD COURT ROAD
RANDALLSTOWN, MD 21133
Medicare Provider Number
210040
Participating Start Date
10/1/2015
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3804
Pharmacy Address
8730 LIBERTY ROAD
RANDALLSTOWN, MD 21133
Pharmacy Comments
Contract Details
Approval Date
4/22/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/16/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Faraaz Yousuf, President and COO
(410) 521-5995
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/22/2019
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