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WALMART PHARMACY 10-5810
DSH450723 METHODIST CHARLTON MEDICAL CENTER
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Covered Entity Details
Entity Name
METHODIST CHARLTON MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450723
Entity Address
3500 WEST WHEATLAND ROAD
DALLAS, TX 75237-3460
Medicare Provider Number
450723
Participating Start Date
7/1/2005
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-5810
Pharmacy Address
7075 W WHEATLAND RD
DALLAS, TX 75249
Pharmacy Comments
Contract Details
Approval Date
7/15/2019
Contract Begin Date
10/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/5/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jon T Albrecht, Corporate VP, Chief Pharmacy Officer
(214) 947-2504
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
7/15/2019
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