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WAL-MART PHARMACY 10-1186
DSH450424 Houston Methodist Baytown Hospital
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Covered Entity Details
Entity Name
Houston Methodist Baytown Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450424
Entity Address
4401 GARTH ROAD
BAYTOWN, TX 77521-2122
Medicare Provider Number
450424
Participating Start Date
4/1/2009
Last Recertification Date
8/21/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1186
Pharmacy Address
2121 US BYPASS 146
LIBERTY, TX 77575
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
Becky P Chalupa, Vice President / Chief Nursing Officer
(281) 420-8602
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
10/15/2020
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