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WAL-MART PHARMACY 10-5315
DSH290019 CARSON TAHOE REGIONAL HEALTHCARE
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Covered Entity Details
Entity Name
CARSON TAHOE REGIONAL HEALTHCARE
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH290019
Entity Address
1600 MEDICAL PARKWAY
CARSON CITY, NV 89703
Medicare Provider Number
290019
Participating Start Date
10/1/2024
Last Recertification Date
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
10/7/2022
Contract Begin Date
1/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/25/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Katie Kucera, Chief Financial Officer
(775) 445-8000 Ext: 5543
Contract Pharmacy Representative
Walmart
Julie Howard, 340B Program Manager
(479) 277-1498
Signed By Date
10/7/2022
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