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WAL-MART PHARMACY 10-5315
DSH390194 Blue Mountain Hospital
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Covered Entity Details
Entity Name
Blue Mountain Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH390194
Entity Address
211 North 12th Street
Lehighton, PA 18235
Medicare Provider Number
390194
Participating Start Date
7/1/2013
Last Recertification Date
8/18/2020
Entity Termination Date
7/1/2021
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
Contract Termination Date
Termination Reason
7/15/2020
Agreement registered in error
Contacts
Covered Entity Signing Official
Andrea Andrae, Director of Finance
(610) 377-7003
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
7/15/2020
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