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WAL-MART PHARMACY 10-2874
DSH330153 Ellis Hospital
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Covered Entity Details
Entity Name
Ellis Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330153
Entity Address
1101 Nott Street
Schenectady, NY 12308
Medicare Provider Number
330153
Participating Start Date
7/1/2012
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2874
Pharmacy Address
200 DUTCH MEADOWS LANE
GLENVILLE, NY 12302
Pharmacy Comments
Contract Details
Approval Date
10/18/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Marc Mesick, CFO & VP of Finance
(518) 243-4144
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
10/18/2016
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