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WAL-MART PHARMACY 10-5315
DSH050122 DAMERON HOSPITAL ASSOCIATION
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Covered Entity Details
Entity Name
DAMERON HOSPITAL ASSOCIATION
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050122
Entity Address
525 WEST ACACIA STREET
STOCKTON, CA 95203
Medicare Provider Number
050122
Participating Start Date
10/1/2006
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
10/14/2019
Contract Begin Date
1/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/7/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Denise Hair, CNO
(209) 461-3133
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/14/2019
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