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WAL-MART STORES EAST, LP
DSH330223 MASSENA MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
MASSENA MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330223
Entity Address
1 HOSPITAL DRIVE
MASSENA, NY 13662
Medicare Provider Number
330223
Participating Start Date
7/1/2010
Last Recertification Date
9/7/2016
Entity Termination Date
4/1/2017
Pharmacy Details
Pharmacy Name
WAL-MART STORES EAST, LP
Pharmacy Address
WAL-MART PHARMACY 10-1946
43 STEPHENVILLE ST
MASSENA, NY 13662
Pharmacy Comments
Contract Details
Approval Date
1/15/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2017
Covered Entity Terminated
Contacts
Covered Entity Signing Official
James L. Smith, Chief Financial Officer
(315) 769-4207
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/15/2014
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