Contract Pharmacy Details

WAL-MART STORES EAST LP
DSH330084 ALICE HYDE MEDICAL CENTER

Covered Entity Details

Entity Name

ALICE HYDE MEDICAL CENTER

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH330084

Entity Address

133 PARK STREET
MALONE, NY 12953-0729

Medicare Provider Number

330084

Participating Start Date

10/1/2011

Last Recertification Date

8/29/2023

Entity Termination Date

11/27/2023

Pharmacy Details

Pharmacy Name

WAL-MART STORES EAST LP

Pharmacy Address

DBA WALMART PHARMAYCY #10-3334
3222 STATE ROUTE 11
MALONE, NY 12953

Pharmacy Comments

Contract Details

Approval Date

10/24/2012

Contract Begin Date

10/24/2012

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

11/27/2023
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Chris Frauenhofer, V.P. of Finance
(518) 481-2204

Contract Pharmacy Representative

Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374

Signed By Date

9/21/2012

340B Drug Pricing Program Database