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WAL-MART PHARMACY 10-2092
DSH330197 CANTON-POTSDAM HOSPITAL
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Covered Entity Details
Entity Name
CANTON-POTSDAM HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330197
Entity Address
50 LEROY STREET
POTSDAM, NY 13676
Medicare Provider Number
330197
Participating Start Date
1/1/2009
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2092
Pharmacy Address
3000 FORD ST. EXTENSION
OGDENSBURG, NY 13669
Pharmacy Comments
Contract Details
Approval Date
1/13/2016
Contract Begin Date
4/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
RICHARD D. JACOBS, VP FOR FINANCE AND CFO
(315) 261-5100
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
1/13/2016
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