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WALMART PHARMACY 10-5169
DSH330136 MARY IMOGENE BASSETT HOSPITAL
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Covered Entity Details
Entity Name
MARY IMOGENE BASSETT HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330136
Entity Address
1 ATWELL ROAD
COOPERSTOWN, NY 13326
Medicare Provider Number
330136
Participating Start Date
1/1/2022
Last Recertification Date
9/3/2023
Entity Termination Date
7/1/2024
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
1/17/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Guy DiStefano, VP of Financial Operations
(607) 547-3692
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/17/2023
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