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WALLY'S PHARMACY
DSH340003 NORTHERN HOSPITAL DISTRICT OF SURRY COUNTY
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Covered Entity Details
Entity Name
NORTHERN HOSPITAL DISTRICT OF SURRY COUNTY
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH340003
Entity Address
830 ROCKFORD STREET
MOUNT AIRY, NC 27030
Medicare Provider Number
340003
Participating Start Date
7/1/2004
Last Recertification Date
9/5/2018
Entity Termination Date
4/1/2019
Pharmacy Details
Pharmacy Name
WALLY'S PHARMACY
Pharmacy Address
933 ROCKFORD ST STE 5
MOUNT AIRY, NC 27030
Pharmacy Comments
Contract Details
Approval Date
5/26/2011
Contract Begin Date
5/26/2011
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/28/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Contract Pharmacy Representative
Signed By Date
5/6/2011
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