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WAL-MART PHARMACY 10-5315
DSH030024 ST JOSEPH'S HOSPITAL AND MEDICAL CENTER
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Covered Entity Details
Entity Name
ST JOSEPH'S HOSPITAL AND MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH030024
Entity Address
350 W THOMAS ROAD
PHOENIX, AZ 85013
Medicare Provider Number
030024
Participating Start Date
1/1/2005
Last Recertification Date
8/18/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
10/9/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/31/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jeffrey Jackson, Chief Financial Officer
(602) 406-4618
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/9/2019
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