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WAL-MART PHARMACY 10-5997
DSH450844 HOUSTON METHODIST WILLOWBROOK HOSPITAL
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Covered Entity Details
Entity Name
HOUSTON METHODIST WILLOWBROOK HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450844
Entity Address
18220 STATE HIGHWAY 249
HOUSTON, TX 77070-4347
Medicare Provider Number
450844
Participating Start Date
4/1/2018
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5997
Pharmacy Address
9600 PARKSOUTH CT. SUITE 100
ORLANDO, FL 32837
Pharmacy Comments
Contract Details
Approval Date
10/15/2020
Contract Begin Date
1/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Makiltru L Fontenette, ACNO
(281) 757-0976
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/15/2020
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