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WAL-MART PHARMACY 10-5732
RRC330011-00 OUR LADY OF LOURDES MEMORIAL HOSP
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Covered Entity Details
Entity Name
OUR LADY OF LOURDES MEMORIAL HOSP
Subdivision Name
Type
Rural Referral Center
340B ID
RRC330011-00
Entity Address
169 RIVERSIDE DRIVE
BINGHAMTON, NY 13905
Medicare Provider Number
330011
Participating Start Date
7/1/2024
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5732
Pharmacy Address
2 GANNETT DRIVE
JOHNSON CITY, NY 13790
Pharmacy Comments
Contract Details
Approval Date
1/9/2017
Contract Begin Date
3/15/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/1/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Kathryn Connerton, CEO
(607) 798-5328
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
1/9/2017
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