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WALMART PHARMACY 10-4597
DSH330065 NIAGARA FALLS MEMORIAL MEDICAL CENTER
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Covered Entity Details
Entity Name
NIAGARA FALLS MEMORIAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330065
Entity Address
621-10TH STREET
NIAGARA FALLS, NY 14302
Medicare Provider Number
330065
Participating Start Date
10/1/2006
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-4597
Pharmacy Address
886 NIAGARA FALLS BLVD.
NORTH TONAWANDA, NY 14120
Pharmacy Comments
Contract Details
Approval Date
7/21/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Raj Mehta, CFO/Vice President of Finance
(716) 278-4399
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
7/21/2015
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