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WAL-MART PHARMACY 10-3409
DSH220163 UMASS MEMORIAL MEDICAL CENTER
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Covered Entity Details
Entity Name
UMASS MEMORIAL MEDICAL CENTER
Subdivision Name
UNIVERSITY CAMPUS
Type
Disproportionate Share Hospital
340B ID
DSH220163
Entity Address
55 LAKE AVENUE NORTH
WORCESTER, MA 01655
Medicare Provider Number
220163
Participating Start Date
10/1/2003
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3409
Pharmacy Address
20 SOOJIANS DR
LEICESTER, MA 01524
Pharmacy Comments
Contract Details
Approval Date
4/10/2014
Contract Begin Date
7/1/2014
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Alice Shakman, Vice President Operations
(774) 443-0540
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
4/10/2014
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