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WAL-MART PHARMACY 10-1705
DSH330125 ROCHESTER GENERAL HOSPITAL
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Covered Entity Details
Entity Name
ROCHESTER GENERAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330125
Entity Address
1425 PORTLAND AVENUE
ROCHESTER, NY 14621
Medicare Provider Number
330125
Participating Start Date
10/1/2019
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1705
Pharmacy Address
1860 NORTH ROAD
WATERLOO, NY 13165
Pharmacy Comments
Contract Details
Approval Date
4/14/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Hugh Thomas, Executive Vice President, Chief Administrative Officer
(585) 922-4941
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/14/2020
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