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WALMART PHARMACY 10-5717
DSH450024 UNIVERSITY MEDICAL CENTER OF EL PASO
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Covered Entity Details
Entity Name
UNIVERSITY MEDICAL CENTER OF EL PASO
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450024
Entity Address
4815 ALAMEDA AVE.
EL PASO, TX 79905
Medicare Provider Number
450024
Participating Start Date
12/1/1992
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-5717
Pharmacy Address
7831 PASEO DEL NORTE
EL PASO, TX 79912
Pharmacy Comments
Contract Details
Approval Date
4/10/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/29/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
MICHAEL NUNEZ, CFO
(915) 521-7626
Contract Pharmacy Representative
University Medical Center of El Paso
Myron Ray Lewis, Director of Pharmacy
(915) 521-7662
Signed By Date
4/10/2023
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