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WAL-MART PHARMACY 10-2234
DSH330215 Rome Memorial Hospital, Inc.
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Covered Entity Details
Entity Name
Rome Memorial Hospital, Inc.
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330215
Entity Address
1500 N. James Street
Rome, NY 13440
Medicare Provider Number
330215
Participating Start Date
1/1/2014
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2234
Pharmacy Address
5815 ROME TABERG RD
ROME, NY 13440
Pharmacy Comments
Contract Details
Approval Date
4/8/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Nathan Smith, AVP Finance
(315) 338-7597
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
4/8/2024
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