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WAL-MART PHARMACY 10-5315
DSH200001 ST JOSEPH HOSPITAL
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Covered Entity Details
Entity Name
ST JOSEPH HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH200001
Entity Address
360 BROADWAY
BANGOR, ME 04401
Medicare Provider Number
200001
Participating Start Date
1/1/2025
Last Recertification Date
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
4/15/2025
Contract Begin Date
7/1/2025
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Michael Allan Hendrix, Vice of President of Finance
(207) 907-1600
Contract Pharmacy Representative
Walmart
Christian Nava, Sr. Manager, Program Management 340B
(210) 632-0647
Signed By Date
4/15/2025
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