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Walmart Pharmacy 10-7611
SCH200037-00 Franklin Memorial Hospital
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Covered Entity Details
Entity Name
Franklin Memorial Hospital
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH200037-00
Entity Address
111 Franklin Health Commons
Farmington, ME 04938
Medicare Provider Number
200037
Participating Start Date
7/1/2017
Last Recertification Date
9/5/2023
Entity Termination Date
8/20/2024
Pharmacy Details
Pharmacy Name
Walmart Pharmacy 10-7611
Pharmacy Address
2501 Perry Rd
Plainfield, IN 46168
Pharmacy Comments
Contract Details
Approval Date
1/4/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/20/2024
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Daniel Bazemore, Chief Financial Officer
(207) 779-2114
Contract Pharmacy Representative
Walmart
Van Donn, Director of Contracting 340b
(303) 261-5549
Signed By Date
1/4/2024
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