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WAL-MART PHARMACY 10-5315
DSH330084 ALICE HYDE MEDICAL CENTER
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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 PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
7/18/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/27/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Sean Curtin, CFO
(518) 481-2204
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
7/18/2017
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