Contract Pharmacy Details

WAL-MART PHARMACY 10-1792
DSH390086 DUBOIS REGIONAL MEDICAL CENTER

Covered Entity Details

Entity Name

DUBOIS REGIONAL MEDICAL CENTER

Subdivision Name

dba Penn Highlands DuBois

Type

Disproportionate Share Hospital

340B ID

DSH390086

Entity Address

100 HOSPITAL AVENUE
DUBOIS, PA 15801

Medicare Provider Number

390086

Participating Start Date

7/1/2004

Last Recertification Date

8/12/2024

Pharmacy Details

Pharmacy Name

WAL-MART PHARMACY 10-1792

Pharmacy Address

1102 MILLION DOLLAR HIGHWAY
ST MARY'S, PA 15857

Pharmacy Comments

Contract Details

Approval Date

2/24/2012

Contract Begin Date

2/24/2012

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Patricia Cressley, CFO
(814) 375-6299

Contract Pharmacy Representative

Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374

Signed By Date

2/24/2012

340B Drug Pricing Program Database