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WALMART PHARMACY 10-5169
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
WALMART PHARMACY 10-5169
Pharmacy Address
2252 NORTH 8TH STREET
SUITE A
ROGERS, AR 72756
Pharmacy Comments
Contract Details
Approval Date
1/17/2023
Contract Begin Date
4/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
11/19/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Shahin Motakef, CEO
(254) 724-6583
Contract Pharmacy Representative
Wal-Mart
Marcus Osbourne, VP of Health and Wellness Transformation
(479) 204-9374
Signed By Date
1/17/2023
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