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WALMART PHARMACY 10-5169
DSH330084 ALICE HYDE MEDICAL CENTER
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Covered Entity Details
Entity Name
ALICE HYDE MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330084
Entity Address
133 PARK STREET
MALONE, NY 12953-0729
Medicare Provider Number
330084
Participating Start Date
10/1/2011
Last Recertification Date
8/29/2023
Entity Termination Date
11/27/2023
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-5169
Pharmacy Address
2252 NORTH 8TH STREET
SUITE A
ROGERS, AR 72756
Pharmacy Comments
Contract Details
Approval Date
1/15/2023
Contract Begin Date
2/15/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/27/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Matej Kollar, Vice President/Chief Financial Officer
(518) 481-8065
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
1/15/2023
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