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WAL-MART PHARMACY 10-1731
DSH330265 Clifton Springs Hospital
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Covered Entity Details
Entity Name
Clifton Springs Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330265
Entity Address
2 Coulter Road
Clifton Springs, NY 14432
Medicare Provider Number
330265
Participating Start Date
7/1/2012
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1731
Pharmacy Address
990 RT 5 & 20
GENEVA, NY 14456
Pharmacy Comments
Contract Details
Approval Date
1/16/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Donna Smith, VP of Operations
(315) 462-0100
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/16/2014
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