Contract Pharmacy Details

WAL-MART PHARMACY 10-5315
DSH380075 PROVIDENCE MEDFORD MEDICAL CENTER

Covered Entity Details

Entity Name

PROVIDENCE MEDFORD MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH380075

Entity Address

1111 CRATER LAKE AVENUE
MEDFORD, OR 97504

Medicare Provider Number

380075

Participating Start Date

7/1/2015

Last Recertification Date

8/16/2024

Pharmacy Details

Pharmacy Name

WAL-MART PHARMACY 10-5315

Pharmacy Address

2354 COMMERCE PARK DR.
ORLANDO, FL 32819

Pharmacy Comments

Contract Details

Approval Date

7/15/2020

Contract Begin Date

10/1/2020

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Christopher Pizzi, Chief Operating Officer
(541) 732-5195

Contract Pharmacy Representative

Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498

Signed By Date

7/15/2020

340B Drug Pricing Program Database