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WAL-MART PHARMACY 10-1367
DSH110069 HOUSTON MEDICAL CENTER
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Covered Entity Details
Entity Name
HOUSTON MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH110069
Entity Address
1601 WATSON BLVD
WARNER ROBINS, GA 31093
Medicare Provider Number
110069
Participating Start Date
7/1/2010
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1367
Pharmacy Address
2720 WATSON BLVD
WARNER ROBINS, GA 31093
Pharmacy Comments
Contract Details
Approval Date
4/11/2022
Contract Begin Date
7/1/2022
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/31/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Sean Whilden, Vice-President/Chief Financial Officer
(478) 542-7959
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/11/2022
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