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WAL-MART PHARMACY 10-5070
DSH290007 UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA
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Covered Entity Details
Entity Name
UNIVERSITY MEDICAL CENTER OF SOUTHERN NEVADA
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH290007
Entity Address
1800 W Charleston Blvd.
LAS VEGAS, NV 89102
Medicare Provider Number
290007
Participating Start Date
7/1/1994
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5070
Pharmacy Address
5200 S FORT APACHE RD
LAS VEGAS(SW2), NV 89148
Pharmacy Comments
Contract Details
Approval Date
10/12/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
3/31/2022
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Mason Van Houweling, CEO
(702) 383-3862
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/12/2020
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