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WAL-MART PHARMACY 10-5997
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 10-5997
Pharmacy Address
9600 PARKSOUTH CT. SUITE 100
ORLANDO, FL 32837
Pharmacy Comments
Contract Details
Approval Date
10/15/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jonathan Thomas Swiatkowski, EVP, Chief Financial Officer
(716) 859-8836
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
10/15/2014
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