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WAL-MART PHARMACY 10-0402
CAH191302-00 ST. MARTIN HOSPITAL
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Covered Entity Details
Entity Name
ST. MARTIN HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH191302-00
Entity Address
210 CHAMPAGNE BLVD.
BREAUX BRIDGE, LA 70517
Medicare Provider Number
191302
Participating Start Date
9/28/2010
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0402
Pharmacy Address
1932 REES STREET
BREAUX BRIDGE, LA 70517
Pharmacy Comments
Contract Details
Approval Date
1/15/2021
Contract Begin Date
4/1/2021
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Glenn Dailey, CEO
(337) 507-1201
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/15/2021
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