Contract Pharmacy Details

WAL-MART PHARMACY 10-5497
SCH330157-00 SAMARITAN MEDICAL CENTER

Covered Entity Details

Entity Name

SAMARITAN MEDICAL CENTER

Subdivision Name

Type

Sole Community Hospital

340B ID

SCH330157-00

Entity Address

830 WASHINGTON STREET
WATERTOWN, NY 13601

Medicare Provider Number

330157

Participating Start Date

10/1/2017

Last Recertification Date

9/16/2019

Entity Termination Date

10/1/2020

Pharmacy Details

Pharmacy Name

WAL-MART PHARMACY 10-5497

Pharmacy Address

25737 US ROUTE #11
EVANS MILLS, NY 13637

Pharmacy Comments

Contract Details

Approval Date

8/8/2017

Contract Begin Date

10/1/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

10/1/2020
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Thomas H. Carman, President & CEO
(315) 785-4121

Contract Pharmacy Representative

Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374

Signed By Date

8/8/2017

340B Drug Pricing Program Database