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WAL-MART STORES EAST, LP
DSH370037 SSM ST ANTHONY HOSPITAL
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Covered Entity Details
Entity Name
SSM ST ANTHONY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH370037
Entity Address
1000 N Lee Ave
OKLAHOMA CITY, OK 73102
Medicare Provider Number
370037
Participating Start Date
10/1/2006
Last Recertification Date
8/31/2024
Pharmacy Details
Pharmacy Name
WAL-MART STORES EAST, LP
Pharmacy Address
WAL-MART PHARMACY 10-3430
9011 NE 23RD ST
OKLAHOMA CITY, OK 73141
Pharmacy Comments
Contract Details
Approval Date
9/26/2012
Contract Begin Date
9/26/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Shasta Manuel, System Vice President/CFO
(405) 272-7282
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
9/7/2012
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