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WAL-MART PHARMACY 10-5727
DSH100175 DESOTO MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
DESOTO MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH100175
Entity Address
900 NORTH ROBERT AVENUE
ARCADIA, FL 34266
Medicare Provider Number
100175
Participating Start Date
1/1/2008
Last Recertification Date
8/28/2019
Entity Termination Date
10/1/2020
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5727
Pharmacy Address
5810 RANCH LAKE BLVD
BRADENTON, FL 34202
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
10/1/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Daniel P. Hogan, CFO
(863) 494-8414
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
7/15/2019
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