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WAL-MART PHARMACY 10-5192
DSH050516 MERCY SAN JUAN MEDICAL CENTER
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Covered Entity Details
Entity Name
MERCY SAN JUAN MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050516
Entity Address
6501 COYLE AVENUE
CARMICHAEL, CA 95608
Medicare Provider Number
050516
Participating Start Date
4/1/2005
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5192
Pharmacy Address
5821 ANTELOPE ROAD
SACRAMENTO, CA 95842
Pharmacy Comments
Contract Details
Approval Date
3/8/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/24/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Bob Pascuzzi, Chief Financial Officer
(916) 537-5000
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/14/2013
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