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WAL-MART CENTRAL FILL 10-2670
CAH451375-00 Liberty Dayton Regional Medical Center
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Covered Entity Details
Entity Name
Liberty Dayton Regional Medical Center
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH451375-00
Entity Address
1353 N.Travis St.
Liberty, TX 77575
Medicare Provider Number
451375
Participating Start Date
7/1/2012
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
WAL-MART CENTRAL FILL 10-2670
Pharmacy Address
608 SPRING HILL DR # 3 SUITE 300
SPRING, TX 77386
Pharmacy Comments
Contract Details
Approval Date
10/15/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Matthew Thornton, CEO
(936) 336-7316 Ext: 149
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/15/2018
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