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WAL-MART PHARMACY 10-2424
CAH331302-02 ELIZABETHTOWN COMMUNITY HOSPITAL
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Covered Entity Details
Entity Name
ELIZABETHTOWN COMMUNITY HOSPITAL
Subdivision Name
WESTPORT HEALTH CENTER
Type
Critical Access Hospital
340B ID
CAH331302-02
Entity Address
6097 NY-9N/Route 22
WESTPORT, NY 12993
Medicare Provider Number
331302
Outpatient Facility Provider Number
Participating Start Date
9/30/2010
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2424
Pharmacy Address
1134 WICKER STREET
TICONDEROGA, NY 12883
Pharmacy Comments
Contract Details
Approval Date
1/13/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/10/2024
Duplicate contract pharmacy record
Contacts
Covered Entity Signing Official
RODNEY BOULA, CEO
(518) 873-3002
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/13/2014
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