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WAL-MART PHARMACY 10-3329
DSH330211 CLAXTON HEPBURN MEDICAL CENTER
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Covered Entity Details
Entity Name
CLAXTON HEPBURN MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330211
Entity Address
214 KING STREET
OGDENSBURG, NY 13669
Medicare Provider Number
330211
Participating Start Date
4/1/2022
Last Recertification Date
9/5/2024
Entity Termination Date
1/1/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3329
Pharmacy Address
7494 US HWY 11
POTSDAM, NY 13676
Pharmacy Comments
Contract Details
Approval Date
1/31/2022
Contract Begin Date
4/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/30/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Richard Duvall, CEO
(315) 713-5237
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/28/2022
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