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WAL-MART PHARMACY 10-0408
DSH450034 CHRISTUS HOSPITAL
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Covered Entity Details
Entity Name
CHRISTUS HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450034
Entity Address
2830 CALDER STREET
BEAUMONT, TX 77702-1048
Medicare Provider Number
450034
Participating Start Date
5/25/2021
Last Recertification Date
8/23/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0408
Pharmacy Address
8585 MEMORIAL BLVD.
PORT ARTHUR, TX 77642
Pharmacy Comments
Contract Details
Approval Date
1/21/2016
Contract Begin Date
4/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/19/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Paul Trevino, CEO, CHRISTUS Health Southeast Texas
(409) 899-7102
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
1/21/2016
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