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WAL-MART PHARMACY 10-5103
DSH390174 THOMAS JEFFERSON UNIVERSITY HOSPITAL
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Covered Entity Details
Entity Name
THOMAS JEFFERSON UNIVERSITY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH390174
Entity Address
111 South 11th Street
Philadelphia, PA 19107
Medicare Provider Number
390174
Participating Start Date
4/1/2006
Last Recertification Date
9/8/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5103
Pharmacy Address
4600 E ROOSEVELT BLVD
BLDG G
PHILADELPHIA, PA 19124
Pharmacy Comments
Contract Details
Approval Date
1/15/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
NEIL G. LUBARSKY, SR VP FOR FINANCE
(215) 955-9993
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
1/15/2020
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