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WAL-MART PHARMACY 10-3320
DSH450176 MISSION HOSPITAL
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Covered Entity Details
Entity Name
MISSION HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450176
Entity Address
900 SOUTH BRYAN
MISSION, TX 78572
Medicare Provider Number
450176
Participating Start Date
10/1/2016
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3320
Pharmacy Address
215 EAST MILE 3 ROAD
PALMHURST, TX 78574
Pharmacy Comments
Contract Details
Approval Date
1/15/2020
Contract Begin Date
4/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/4/2021
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Kennetha Foster, Chief Nursing Officer
(956) 323-9108
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
1/15/2020
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