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WAL-MART PHARMACY 10-2634
CAH301310-00 ANDROSCOGGIN VALLEY HOSPITAL , Inc.
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Covered Entity Details
Entity Name
ANDROSCOGGIN VALLEY HOSPITAL , Inc.
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH301310-00
Entity Address
59 PAGE HILL ROAD
BERLIN, NH 03570-3542
Medicare Provider Number
301310
Participating Start Date
9/29/2010
Last Recertification Date
8/28/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2634
Pharmacy Address
561 MAIN STREET
GORHAM, NH 03581
Pharmacy Comments
Contract Details
Approval Date
9/27/2012
Contract Begin Date
9/27/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
RUSSELL KEENE, CEO
(603) 752-2200
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
9/27/2012
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