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WAL-MART PHARMACY 10-1868
DSH200034 St. Mary's Regional Medical Center
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Covered Entity Details
Entity Name
St. Mary's Regional Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH200034
Entity Address
93 Campus Avenue
Lewiston, ME 04240-6030
Medicare Provider Number
200034
Participating Start Date
10/1/2002
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1868
Pharmacy Address
100 MT AUBURN AVE
AUBURN, ME 04210
Pharmacy Comments
Contract Details
Approval Date
10/19/2012
Contract Begin Date
10/19/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
CAROLYN KASABIAN, CFO
(207) 777-8546
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
9/18/2012
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