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Walmart Pharmacy 10-7611
DSH330090 ARNOT OGDEN MEDICAL CENTER
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Covered Entity Details
Entity Name
ARNOT OGDEN MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330090
Entity Address
600 Roe Ave
ELMIRA, NY 14905
Medicare Provider Number
330090
Participating Start Date
10/27/2012
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
Walmart Pharmacy 10-7611
Pharmacy Address
2501 Perry Rd
Plainfield, IN 46168
Pharmacy Comments
Contract Details
Approval Date
1/7/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ronette Wiley, Senior Vice President and Chief Operating Officer
(607) 737-4486
Contract Pharmacy Representative
Walmart
Van Donn, Director of Contracting 340b
(303) 261-5549
Signed By Date
1/7/2024
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