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WAL-MART PHARMACY 10-0077
DSH450054 SCOTT AND WHITE MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
SCOTT AND WHITE MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450054
Entity Address
2401 S 31ST ST
TEMPLE, TX 76508
Medicare Provider Number
450054
Participating Start Date
4/1/2006
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0077
Pharmacy Address
3701 NORTH MAIN STREET
TAYLOR, TX 76574
Pharmacy Comments
Contract Details
Approval Date
10/1/2012
Contract Begin Date
10/1/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Dennis Laraway, Chief Financial Officer
(254) 724-2111
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
9/5/2012
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