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WAL-MART PHARMACY 10-0290
CAH451371-00 Ascension Seton d/b/a Ascension Seton Edgar B. Davis
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Covered Entity Details
Entity Name
Ascension Seton d/b/a Ascension Seton Edgar B. Davis
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH451371-00
Entity Address
130 HAYS STREET
LULING, TX 78648-3207
Medicare Provider Number
451371
Participating Start Date
8/19/2010
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0290
Pharmacy Address
1114 EAST SARAH DEWITT DR.
GONZALES, TX 78629
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
Apryl Renee Haynes, COO/CNO
(830) 875-7041
Contract Pharmacy Representative
Wal-mart
Laura Levine, Manager Contracting
(479) 204-8550
Signed By Date
7/2/2018
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