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WAL-MART PHARMACY 10-5317
DSH450056 Ascension Seton d/b/a Ascension Seton Medical Center Austin
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Covered Entity Details
Entity Name
Ascension Seton d/b/a Ascension Seton Medical Center Austin
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450056
Entity Address
1201 WEST 38TH STREET
AUSTIN, TX 78705
Medicare Provider Number
450056
Participating Start Date
4/1/2017
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5317
Pharmacy Address
9300 SOUTH IH-35 BLDG. "B"
AUSTIN, TX 78748
Pharmacy Comments
Contract Details
Approval Date
7/2/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/31/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Tad Allen Hatton, VP/COO
(512) 484-3507
Contract Pharmacy Representative
Wal-mart
Laura Levine, Manager Contracting
(479) 204-8550
Signed By Date
7/2/2018
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