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WAL-MART PHARMACY 10-0475
DSH450867 Ascension Seton d/b/a Ascension Seton Northwest
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Covered Entity Details
Entity Name
Ascension Seton d/b/a Ascension Seton Northwest
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450867
Entity Address
11113 RESEARCH BLVD
AUSTIN, TX 78759-5297
Medicare Provider Number
450867
Participating Start Date
7/1/2015
Last Recertification Date
8/16/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0475
Pharmacy Address
2701 SOUTH I.H. 35
ROUND ROCK, TX 78664
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
Margaret Elaine Butler, COO
(512) 324-6046
Contract Pharmacy Representative
Wal-mart
Laura Levine, Manager Contracting
(479) 204-8550
Signed By Date
7/3/2018
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