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WAL-MART PHARMACY 10-4389
CAH301305-00 ALICE PECK DAY MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
ALICE PECK DAY MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH301305-00
Entity Address
10 ALICE PECK DAY DRIVE
LEBANON, NH 03766
Medicare Provider Number
301305
Participating Start Date
4/1/2020
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-4389
Pharmacy Address
WAL-MART STORES EAST, LP
4901 DARTMOUTH COLLEGE HWY
WOODSVILLE, NH 03785
Pharmacy Comments
Contract Details
Approval Date
1/3/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/1/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Todd P Roberts, CFO
(603) 308-0082
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/3/2022
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