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WALMART PHARMACY 10-5169
CAH451376-00 LAVACA MEDICAL CENTER
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Covered Entity Details
Entity Name
LAVACA MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH451376-00
Entity Address
1400 N TEXANA
HALLETTSVILLE, TX 77964-2021
Medicare Provider Number
451376
Participating Start Date
9/30/2010
Last Recertification Date
8/21/2024
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
4/3/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
STEVE BOWEN, ADMINISTRATOR
(361) 798-3671 Ext: 1207
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/3/2023
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