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Walmart Pharmacy 10-7611
DSH330157 SAMARITAN MEDICAL CENTER
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Covered Entity Details
Entity Name
SAMARITAN MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330157
Entity Address
830 WASHINGTON STREET
WATERTOWN, NY 13601
Medicare Provider Number
330157
Participating Start Date
10/1/2020
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
Walmart Pharmacy 10-7611
Pharmacy Address
2501 Perry Rd
Plainfield, IN 46168
Pharmacy Comments
Contract Details
Approval Date
10/10/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Maxine A Briggs, VP Of Fiscal Services/Chief Financial Officer
(315) 755-3605
Contract Pharmacy Representative
Walmart
Van Donn, Director of Contracting 340b
(303) 261-5549
Signed By Date
10/10/2023
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