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WALMART PHARMACY 10-5169
DSH330191 GLENS FALLS HOSPITAL
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Covered Entity Details
Entity Name
GLENS FALLS HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330191
Entity Address
100 PARK ST
GLENS FALLS, NY 12801
Medicare Provider Number
330191
Participating Start Date
10/1/2022
Last Recertification Date
8/12/2024
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
4/6/2023
Contract Begin Date
4/17/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Mitchell J Amado, VP, Senior, Finance & CFO
(518) 926-5113
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/6/2023
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