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WAL-MART PHARMACY 10-5997
SCH330157-00 SAMARITAN MEDICAL CENTER
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Covered Entity Details
Entity Name
SAMARITAN MEDICAL CENTER
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH330157-00
Entity Address
830 WASHINGTON STREET
WATERTOWN, NY 13601
Medicare Provider Number
330157
Participating Start Date
10/1/2017
Last Recertification Date
9/16/2019
Entity Termination Date
10/1/2020
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5997
Pharmacy Address
9600 PARKSOUTH CT. SUITE 100
ORLANDO, FL 32837
Pharmacy Comments
Contract Details
Approval Date
1/8/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Thomas H. Carman, President & CEO
(315) 785-4121
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/8/2020
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