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WAL-MART PHARMACY 10-2540
DSH390086 DUBOIS REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
DUBOIS REGIONAL MEDICAL CENTER
Subdivision Name
dba Penn Highlands DuBois
Type
Disproportionate Share Hospital
340B ID
DSH390086
Entity Address
100 HOSPITAL AVENUE
DUBOIS, PA 15801
Medicare Provider Number
390086
Participating Start Date
7/1/2004
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2540
Pharmacy Address
63 PERKINS ROAD
CLARION, PA 16214
Pharmacy Comments
Contract Details
Approval Date
4/15/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brian Kline, CFO
(814) 375-6377
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
4/15/2021
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