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WAL-MART PHARMACY 10-5317
DSH450124 Dell Seton Medical Center at The University of Texas
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Covered Entity Details
Entity Name
Dell Seton Medical Center at The University of Texas
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450124
Entity Address
1500 RED RIVER ST
AUSTIN, TX 78701
Medicare Provider Number
450124
Participating Start Date
3/11/2021
Last Recertification Date
8/28/2024
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
7/3/2018
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
Christann M Vasquez, President
(512) 324-7074
Contract Pharmacy Representative
Wal-mart
Laura Levine, Manager Contracting
(479) 204-8550
Signed By Date
7/3/2018
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