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WAL-MART STORES EAST LP
DSH330250 CHAMPLAIN VALLEY PHYSICIANS HOSPITAL
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Covered Entity Details
Entity Name
CHAMPLAIN VALLEY PHYSICIANS HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330250
Entity Address
75 BEEKMAN STREET
PLATTSBURGH, NY 12901
Medicare Provider Number
330250
Participating Start Date
6/3/2019
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
WAL-MART STORES EAST LP
Pharmacy Address
DBA WALMART PHARMAYCY #10-3334
3222 STATE ROUTE 11
MALONE, NY 12953
Pharmacy Comments
Contract Details
Approval Date
4/11/2023
Contract Begin Date
5/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/5/2024
Business decision by covered entity and/or pharmacy
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
4/11/2023
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