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WAL-MART PHARMACY 10-1919
CAH201303-00 PENOBSCOT VALLEY HOSPITAL
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Covered Entity Details
Entity Name
PENOBSCOT VALLEY HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH201303-00
Entity Address
7 TRANSALPINE ROAD
LINCOLN, ME 04457
Medicare Provider Number
201303
Participating Start Date
4/1/2011
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1919
Pharmacy Address
250 WEST BROADWAY
LINCOLN, ME 04457
Pharmacy Comments
Contract Details
Approval Date
10/1/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ann Marie Rush, CFO
(207) 794-7229
Contract Pharmacy Representative
Wal--Mart
Marcus Osborne, Sales & Contracting
(479) 204-8452
Signed By Date
10/1/2014
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