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WAL-MART PHARMACY 10-2092
SCH330211-00 Claxton Hepburn Medical Center
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Covered Entity Details
Entity Name
Claxton Hepburn Medical Center
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH330211-00
Entity Address
214 King Street
Ogdensburg, NY 13669
Medicare Provider Number
330211
Participating Start Date
1/1/2014
Last Recertification Date
8/17/2021
Entity Termination Date
4/1/2022
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2092
Pharmacy Address
3000 FORD ST. EXTENSION
OGDENSBURG, NY 13669
Pharmacy Comments
Contract Details
Approval Date
1/14/2014
Contract Begin Date
4/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2022
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Kelley M. Tiernan, CFO
(315) 713-5350
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/14/2014
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