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WAL-MART PHARMACY 10-2370
DSH330232 SETON HEALTH SYSTEM
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Covered Entity Details
Entity Name
SETON HEALTH SYSTEM
Subdivision Name
St. Mary's Hospital
Type
Disproportionate Share Hospital
340B ID
DSH330232
Entity Address
1300 MASSACHUSETTS AVE
TROY, NY 12180
Medicare Provider Number
330232
Participating Start Date
10/1/2009
Last Recertification Date
8/28/2018
Entity Termination Date
4/1/2019
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2370
Pharmacy Address
760 HOOSICK RD
TROY, NY 12180
Pharmacy Comments
Contract Details
Approval Date
4/24/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/24/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Daniel Kochie, CFO
(518) 268-5335
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
4/24/2014
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