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WAL-MART PHARMACY 10-4403
DSH330191 GLENS FALLS HOSPITAL
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Covered Entity Details
Entity Name
GLENS FALLS HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330191
Entity Address
100 PARK ST
GLENS FALLS, NY 12801
Medicare Provider Number
330191
Participating Start Date
10/1/2022
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-4403
Pharmacy Address
24 QUAKER RIDGE BLVD.
QUEENSBURY, NY 12804
Pharmacy Comments
Contract Details
Approval Date
8/24/2022
Contract Begin Date
10/1/2022
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Mitchell J Amado, VP, Senior, Finance & CFO
(518) 926-5113
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
7/13/2022
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