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WAL-MART PHARMACY 10-5315
DSH450369 CHILDRESS REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
CHILDRESS REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450369
Entity Address
901 US HWY 83 NORTH
CHILDRESS, TX 79201
Medicare Provider Number
450369
Participating Start Date
4/1/2016
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
4/14/2021
Contract Begin Date
7/1/2021
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Kevin Latimer, CEO
(940) 937-9178
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
4/14/2021
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