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WAL-MART PHARMACY 10-5315
DSH360037 ST. VINCENT CHARITY MEDICAL CENTER
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Covered Entity Details
Entity Name
ST. VINCENT CHARITY MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH360037
Entity Address
2351 EAST 22ND STREET
CLEVELAND, OH 44115
Medicare Provider Number
360037
Participating Start Date
1/1/2001
Last Recertification Date
9/12/2022
Entity Termination Date
1/1/2023
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
10/15/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/15/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
JOHN Rusnaczyk, CFO
(216) 363-7718 Ext: 37718
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/15/2019
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