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WAL-MART PHARMACY 10-1789
DSH050336 Adventist Health Lodi Memorial
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Covered Entity Details
Entity Name
Adventist Health Lodi Memorial
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050336
Entity Address
975 S. FAIRMONT AVENUE
LODI, CA 95240
Medicare Provider Number
050336
Participating Start Date
10/1/2015
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1789
Pharmacy Address
1601 S. LOWER SACRAMENTO RD.
LODI, CA 95242
Pharmacy Comments
Contract Details
Approval Date
10/14/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Terry Deak, VP & Chief Financial Officer
(209) 339-7898
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
10/14/2015
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