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WAL-MART PHARMACY 10-2123
DSH450801 CHRISTUS ST MICHAEL
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Covered Entity Details
Entity Name
CHRISTUS ST MICHAEL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450801
Entity Address
2600 ST MICHAEL DRIVE
TEXARKANA, TX 75503
Medicare Provider Number
450801
Participating Start Date
4/1/2015
Last Recertification Date
8/14/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-2123
Pharmacy Address
4000 NEW BOSTON ROAD
TEXARKANA, TX 75501
Pharmacy Comments
Contract Details
Approval Date
4/12/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/1/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jason Adams, President
(903) 614-2001
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/12/2023
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