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WALMART PHARMACY 10-3879
DSH190118 DESOTO REGIONAL HEALTH SYSTEM
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Covered Entity Details
Entity Name
DESOTO REGIONAL HEALTH SYSTEM
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190118
Entity Address
207 JEFFERSON STREET
MANSFIELD, LA 71052
Medicare Provider Number
190118
Participating Start Date
7/1/2006
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-3879
Pharmacy Address
1495 OBRIE STREET
ZWOLLE, LA 71486
Pharmacy Comments
Contract Details
Approval Date
4/1/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/21/2019
Pharmacy closed
Contacts
Covered Entity Signing Official
SANDRA ANDERSON, CFO
(318) 872-4610 Ext: 3102
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
4/1/2015
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