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WALMART PHARMACY 10-5169
DSH330047 ST. MARYS HEALTHCARE
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Covered Entity Details
Entity Name
ST. MARYS HEALTHCARE
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330047
Entity Address
427 GUY PARK AVENUE
AMSTERDAM, NY 12010
Medicare Provider Number
330047
Participating Start Date
10/1/2009
Last Recertification Date
8/14/2024
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
7/3/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/2/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Keith Waters, Vice President of Finance/CFO
(518) 770-7583
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
7/3/2023
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