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WAL-MART PHARMACY 10-2682
CAH471301-00 GIFFORD MEDICAL CENTER
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Covered Entity Details
Entity Name
GIFFORD MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH471301-00
Entity Address
44 SOUTH MAIN STREET
RANDOLPH, VT 05060
Medicare Provider Number
471301
Participating Start Date
7/1/2011
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2682
Pharmacy Address
282 BERLIN MALL ROAD UNIT #1
BERLIN, VT 05602
Pharmacy Comments
Contract Details
Approval Date
1/10/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/27/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jeff Hebert, CFO
(802) 728-2356
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/10/2014
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