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WAL-MART PHARMACY 10-5315
DSH200034 St. Mary's Regional Medical Center
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Covered Entity Details
Entity Name
St. Mary's Regional Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH200034
Entity Address
93 Campus Avenue
Lewiston, ME 04240-6030
Medicare Provider Number
200034
Participating Start Date
10/1/2002
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
7/14/2020
Contract Begin Date
10/1/2020
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Michael Hendrix, CFO/Treasurer
(207) 777-8865
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
7/14/2020
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