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WAL-MART PHARMACY 10-2905
DSH330104 MONTEFIORE NYACK HOSPITAL
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Covered Entity Details
Entity Name
MONTEFIORE NYACK HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330104
Entity Address
160 NORTH MIDLAND AVENUE
NYACK, NY 10960
Medicare Provider Number
330104
Participating Start Date
4/1/2006
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2905
Pharmacy Address
250 ROUTE #59
SUFFERN, NY 10901
Pharmacy Comments
Contract Details
Approval Date
1/9/2015
Contract Begin Date
4/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/14/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
John S. Burke, CFO
(845) 348-2107
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
1/9/2015
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