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WAL-MART PHARMACY 10-3560
DSH220074 SOUTHCOAST HOSPITALS GROUP, INC
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Covered Entity Details
Entity Name
SOUTHCOAST HOSPITALS GROUP, INC
Subdivision Name
DBA CHARLTON MEMORIAL HOSPITAL
Type
Disproportionate Share Hospital
340B ID
DSH220074
Entity Address
363 HIGHLAND AVENUE
FALL RIVER, MA 02720
Medicare Provider Number
220074
Participating Start Date
7/1/2004
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3560
Pharmacy Address
638 QUEQUECHAN STREET
FALL RIVER, MA 02721
Pharmacy Comments
Contract Details
Approval Date
1/16/2015
Contract Begin Date
4/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/10/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
John Evans, Executive Director Pharmacy
(508) 973-7102
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/16/2015
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