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WAL-MART PHARMACY 10-2202
CAH201310-00 BRIDGTON HOSPITAL
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Covered Entity Details
Entity Name
BRIDGTON HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH201310-00
Entity Address
10 HOSPITAL DRIVE
BRIDGTON, ME 04009
Medicare Provider Number
201310
Participating Start Date
8/31/2010
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2202
Pharmacy Address
30 LANDING ROAD
WINDHAM, ME 04062
Pharmacy Comments
Contract Details
Approval Date
11/28/2012
Contract Begin Date
1/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/30/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Matthew Cox, CFO
(207) 795-0111
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
10/23/2012
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