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WAL-MART PHARMACY 10-5172
SCH100106-00 DOCTORS MEMORIAL
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Covered Entity Details
Entity Name
DOCTORS MEMORIAL
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH100106-00
Entity Address
333 BYRON BUTLER PARKWAY
PERRY, FL 32347
Medicare Provider Number
100106
Participating Start Date
10/1/2019
Last Recertification Date
8/23/2023
Entity Termination Date
11/16/2023
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5172
Pharmacy Address
1900 SOUTH JEFFERSON ST
PERRY, FL 32348
Pharmacy Comments
Contract Details
Approval Date
7/23/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/16/2023
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Thomas J. Stone, Chief Executive Officer
(850) 584-0886
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
7/12/2019
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