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WALMART PHARMACY 10-4597
DSH330188 Mount St. Mary's Hospital and Health Center
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Covered Entity Details
Entity Name
Mount St. Mary's Hospital and Health Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330188
Entity Address
5300 MILITARY ROAD
LEWISTON, NY 14092
Medicare Provider Number
330188
Participating Start Date
1/1/2014
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-4597
Pharmacy Address
886 NIAGARA FALLS BLVD.
NORTH TONAWANDA, NY 14120
Pharmacy Comments
Contract Details
Approval Date
4/18/2016
Contract Begin Date
7/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
GARY TUCKER, PRESIDENT/CEO
(716) 298-2004
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
4/18/2016
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