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WAL-MART PHARMACY 10-2945
DSH390076 BRANDYWINE HOSPITAL
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Covered Entity Details
Entity Name
BRANDYWINE HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH390076
Entity Address
201 REECEVILLE ROAD
COATSVILLE, PA 19320
Medicare Provider Number
390076
Participating Start Date
10/1/2020
Last Recertification Date
9/10/2021
Entity Termination Date
4/1/2022
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2945
Pharmacy Address
100 COMMONS DRIVE
PARKSBURG, PA 19365
Pharmacy Comments
Contract Details
Approval Date
1/6/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/14/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
michael francis szymanski, cfo
(610) 383-8009
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/6/2021
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