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WAL-MART PHARMACY 10-2556
DSH050107 MARIAN MEDICAL CENTER
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Covered Entity Details
Entity Name
MARIAN MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050107
Entity Address
1400 E CHURCH ST
SANTA MARIA, CA 93454
Medicare Provider Number
050107
Participating Start Date
1/1/2005
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2556
Pharmacy Address
1168 WEST BRANCH STREET
ARROYO GRANDE, CA 93420
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
1/4/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
SUE ANDERSEN, CFO
(805) 739-3110
Contract Pharmacy Representative
Walmart
Julie Howard, 340b Program Manager
(479) 739-1973 Ext: 4792771498
Signed By Date
10/14/2019
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