Contract Pharmacy Details

WILCOX PHARMACY
SCH470005-00 RUTLAND REGIONAL MEDICAL CENTER

Covered Entity Details

Entity Name

RUTLAND REGIONAL MEDICAL CENTER

Subdivision Name

Type

Sole Community Hospital

340B ID

SCH470005-00

Entity Address

160 ALLEN STREET
RUTLAND, VT 05701

Medicare Provider Number

470005

Participating Start Date

9/30/2010

Last Recertification Date

8/24/2015

Entity Termination Date

7/1/2016

Pharmacy Details

Pharmacy Name

WILCOX PHARMACY

Pharmacy Address

252 STRATTON ROAD
RUTLAND, VT 05701

Pharmacy Comments

Contract Details

Approval Date

7/12/2011

Contract Begin Date

7/12/2011

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

7/1/2016
Covered Entity Terminated

Contacts

Covered Entity Signing Official

EDWARD OGORZALEK, CFO
(802) 747-1610

Contract Pharmacy Representative

Richard J. Wilcox, President
(802) 775-3351

Signed By Date

6/13/2011