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WAL-MART PHARMACY 10-2683
DSH220016 BAYSTATE FRANKLIN MEDICAL CENTER
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Covered Entity Details
Entity Name
BAYSTATE FRANKLIN MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH220016
Entity Address
164 HIGH STREET
GREENFIELD, MA 01301
Medicare Provider Number
220016
Participating Start Date
4/1/2009
Last Recertification Date
8/12/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2683
Pharmacy Address
337 RUSSELL STREET
HADLEY, MA 01035
Pharmacy Comments
Contract Details
Approval Date
9/19/2012
Contract Begin Date
9/19/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/1/2018
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Chuck Gijanto, President
(413) 773-2611
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
8/16/2012
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