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WALMART PHARMACY 10-5169
CAH331321-00 ALICE HYDE MEDICAL CENTER
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Covered Entity Details
Entity Name
ALICE HYDE MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH331321-00
Entity Address
133 PARK STREET
MALONE, NY 12953
Medicare Provider Number
331321
Participating Start Date
11/27/2023
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-5169
Pharmacy Address
2252 NORTH 8TH STREET
SUITE A
ROGERS, AR 72756
Pharmacy Comments
Contract Details
Approval Date
4/9/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Matej Kollar, Vice President/Chief Financial Officer
(518) 481-8065
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
4/9/2024
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