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WALMART PHARMACY 10-4503
DSH450051 METHODIST DALLAS MEDICAL CENTER
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Covered Entity Details
Entity Name
METHODIST DALLAS MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450051
Entity Address
1441 NORTH BECKLEY AVENUE
DALLAS, TX 75203
Medicare Provider Number
450051
Participating Start Date
7/1/2005
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-4503
Pharmacy Address
2650 S HWY 161
GRAND PRAIRIE, TX 75052
Pharmacy Comments
Contract Details
Approval Date
10/14/2021
Contract Begin Date
1/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/12/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jon T Albrecht, Corporate VP, Chief Pharmacy Officer
(214) 947-2504
Contract Pharmacy Representative
Walmart
George Flaherty, Senior Director Payer Programs
(479) 204-9374
Signed By Date
10/14/2021
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