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WAL-MART PHARMACY 10-5495
DSH390180 Crozer Chester Medical Center
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Covered Entity Details
Entity Name
Crozer Chester Medical Center
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH390180
Entity Address
One Medical Center Blvd
Upland, PA 19013-3995
Medicare Provider Number
390180
Participating Start Date
4/1/2012
Last Recertification Date
8/11/2015
Entity Termination Date
10/1/2016
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5495
Pharmacy Address
50 NORTH MACDADE BLVD.
GLENOLDEN, PA 19036
Pharmacy Comments
Contract Details
Approval Date
8/29/2012
Contract Begin Date
9/1/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/30/2016
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Phillip Ryan, Chief Financial Officer
(610) 338-8228
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
8/16/2012
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