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WAL-MART PHARMACY 10-5315
DSH050336 Adventist Health Lodi Memorial
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Covered Entity Details
Entity Name
Adventist Health Lodi Memorial
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050336
Entity Address
975 S. FAIRMONT AVENUE
LODI, CA 95240
Medicare Provider Number
050336
Participating Start Date
10/1/2015
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
1/9/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jason Whitney, Finance Officer
(209) 339-7477
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/9/2020
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