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WAL-MART PHARMACY 10-5315
DSH330250 CHAMPLAIN VALLEY PHYSICIANS HOSPITAL
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Covered Entity Details
Entity Name
CHAMPLAIN VALLEY PHYSICIANS HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330250
Entity Address
75 BEEKMAN STREET
PLATTSBURGH, NY 12901
Medicare Provider Number
330250
Participating Start Date
6/3/2019
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
10/4/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/30/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
JOYCE RAFFERTY, VICE PRESIDENT OF FINANCE
(518) 562-7047
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
10/4/2016
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