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WAL-MART PHARMACY 10-1871
DSH330157 SAMARITAN MEDICAL CENTER
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Covered Entity Details
Entity Name
SAMARITAN MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330157
Entity Address
830 WASHINGTON STREET
WATERTOWN, NY 13601
Medicare Provider Number
330157
Participating Start Date
10/1/2020
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1871
Pharmacy Address
20823 ST. - RT. #3
WATERTOWN, NY 13601
Pharmacy Comments
Contract Details
Approval Date
7/16/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Maxine A Briggs, VP Of Fiscal Services/Chief Financial Officer
(315) 755-3605
Contract Pharmacy Representative
WAL-MART
MARCUS OSBORNE, VP OF HEALTH & WELLNESS SALES AND CONTRACTING
(479) 204-9374
Signed By Date
7/12/2020
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