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WAL-MART PHARMACY 10-2480
SCH390125-00 WAYNE MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
WAYNE MEMORIAL HOSPITAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH390125-00
Entity Address
601 PARK ST
HONESDALE, PA 18431
Medicare Provider Number
390125
Participating Start Date
4/1/2018
Last Recertification Date
9/12/2023
Entity Termination Date
1/1/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2480
Pharmacy Address
723A OLD WILLOW AVE
HONESDALE, PA 18431
Pharmacy Comments
Contract Details
Approval Date
10/5/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/26/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Patricia Dunsinger, CFO
(570) 253-8133
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/5/2020
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