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WALMART PHARMACY 10-5169
DSH220052 BROCKTON HOSPITAL, INC
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Covered Entity Details
Entity Name
BROCKTON HOSPITAL, INC
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH220052
Entity Address
680 CENTRE STREET
BROCKTON, MA 02302
Medicare Provider Number
220052
Participating Start Date
1/1/2004
Last Recertification Date
8/13/2024
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
1/23/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Stephen Borges, Vice President, Finance Operations
(508) 941-7571
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/23/2023
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