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WAL-MART PHARMACY 10-4423
DSH210001A MERITUS MEDICAL CENTER
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Covered Entity Details
Entity Name
MERITUS MEDICAL CENTER
Subdivision Name
John R Marsh Cancer Center - Outpatient Oncology/Infusion Center
Type
Disproportionate Share Hospital
340B ID
DSH210001A
Entity Address
Ste 129, 11110 Medical Campus Rd
129
Hagerstown, MD 21742
Medicare Provider Number
210001
Outpatient Facility Provider Number
Participating Start Date
7/1/2018
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-4423
Pharmacy Address
5680 HAMMONDS MILL ROAD
MARTINSBURG, WV 25404
Pharmacy Comments
Contract Details
Approval Date
4/15/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/5/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Tom T Chan, CFO
(301) 790-8101
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/15/2020
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