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WAL-MART PHARMACY 10-0275
DSH450395 Memorial Medical Center-Livingston
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Covered Entity Details
Entity Name
Memorial Medical Center-Livingston
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450395
Entity Address
1717 Hwy 59 Bypass
Livingston, TX 77351
Medicare Provider Number
450395
Participating Start Date
1/1/2012
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0275
Pharmacy Address
1620 W. CHURCH
LIVINGSTON, TX 77351
Pharmacy Comments
Contract Details
Approval Date
10/12/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/24/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kristina Froese, VP of Operations
(936) 329-8726
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/12/2018
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