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WAL-MART PHARMACY 10-2225
DSH410011 Landmark Medical Center
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Covered Entity Details
Entity Name
Landmark Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH410011
Entity Address
115 Cass ave
Woonsocket, RI 02895
Medicare Provider Number
410011
Participating Start Date
10/1/2018
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2225
Pharmacy Address
7 DOWLING VILLAGE BLVD
NORTH SMITHFIELD, RI 02896
Pharmacy Comments
Contract Details
Approval Date
1/15/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/21/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
scott brown, cfo
(401) 769-4100 Ext: 6601
Contract Pharmacy Representative
Landmark Medical Center
Ted gorham, Directory of Pharmacy
(401) 769-4100
Signed By Date
1/15/2020
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