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WAL-MART PHARMACY 10-1909
DSH330005 KALEIDA HEALTH
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Covered Entity Details
Entity Name
KALEIDA HEALTH
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330005
Entity Address
100 High Street
BUFFALO, NY 14203
Medicare Provider Number
330005
Participating Start Date
4/1/2006
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1909
Pharmacy Address
1540 MILITARY ROAD
NIAGARA FALLS, NY 14304
Pharmacy Comments
Contract Details
Approval Date
10/15/2012
Contract Begin Date
10/15/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/1/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Joseph Kessler, CFO
(716) 859-8836
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
9/13/2012
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