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WAL-MART PHARMACY 10-5298
DSH340032 GASTON MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
GASTON MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH340032
Entity Address
2525 COURT DRIVE
GASTONIA, NC 28054
Medicare Provider Number
340032
Participating Start Date
1/1/2025
Last Recertification Date
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5298
Pharmacy Address
223 N MYRTLE SCHOOL RD
GASTONIA(W), NC 28052
Pharmacy Comments
Contract Details
Approval Date
1/17/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/24/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
David O’Connor, CFO
(704) 834-2127
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/17/2014
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