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WALMART PHARMACY 10-5169
DSH420065 BON SECOURS - ST. FRANCIS XAVIER HOSPITAL
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Covered Entity Details
Entity Name
BON SECOURS - ST. FRANCIS XAVIER HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH420065
Entity Address
2095 HENRY TECKLENBURG DRIVE
CHARLESTON, SC 29414
Medicare Provider Number
420065
Participating Start Date
10/1/2010
Last Recertification Date
9/4/2024
Entity Termination Date
7/1/2025
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
4/19/2023
Contract Begin Date
7/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/18/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Christopher Lawrence Glenn, Director of Finance
(843) 789-1705
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/19/2023
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