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WALMART PHARMACY 10-5169
CAH331305-00 O'Connor Hospital
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Covered Entity Details
Entity Name
O'Connor Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH331305-00
Entity Address
460 Andes Road
Delhi, NY 13753
Medicare Provider Number
331305
Participating Start Date
2/13/2013
Last Recertification Date
8/29/2024
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
4/21/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/20/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Guy DiStefano, VP of Financial Operations
(607) 547-3692
Contract Pharmacy Representative
Wal-mart
Laura Levine, Manager Contracting
(479) 204-8550
Signed By Date
4/21/2023
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