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WAL-MART PHARMACY 10-1966
DSH330238 NICHOLAS H. NOYES MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
NICHOLAS H. NOYES MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330238
Entity Address
111 CLARA BARTON STREET
DANSVILLE, NY 14437
Medicare Provider Number
330238
Participating Start Date
10/1/2017
Last Recertification Date
8/15/2024
Entity Termination Date
1/1/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1966
Pharmacy Address
4235 VETERAN DRIVE
GENESEO, NY 14454
Pharmacy Comments
Contract Details
Approval Date
10/12/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/29/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Mark F Prunoske, SVP/CFO
(585) 335-4306
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/12/2020
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