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WAL-MART PHARMACY 10-3298
DSH450018 UNIVERSITY OF TEXAS MEDICAL BRANCH
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Covered Entity Details
Entity Name
UNIVERSITY OF TEXAS MEDICAL BRANCH
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450018
Entity Address
301 UNIVERSITY BLVD
GALVESTON, TX 77555
Medicare Provider Number
450018
Participating Start Date
4/1/1994
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-3298
Pharmacy Address
255 FM 518
KEMAH, TX 77565
Pharmacy Comments
Contract Details
Approval Date
4/13/2020
Contract Begin Date
7/1/2020
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/27/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Carolee A. King, Senior Vice President & General Counsel
(409) 772-1904
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/13/2020
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