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WAL-MART PHARMACY 10-1907
DSH470011 Brattleboro Memorial Hospital
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Covered Entity Details
Entity Name
Brattleboro Memorial Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH470011
Entity Address
17 Belmont Avenue
Brattleboro, VT 05301
Medicare Provider Number
470011
Participating Start Date
7/1/2014
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1907
Pharmacy Address
724 BRATTLEBORO ROAD
HINSDALE, NH 03451
Pharmacy Comments
Contract Details
Approval Date
7/6/2016
Contract Begin Date
10/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Michael Rogers, Vice President, Finance
(802) 257-8279
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
7/6/2016
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