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Walmart Pharmacy 10-7611
DSH450237 SANTA ROSA HEALTHCARE
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Covered Entity Details
Entity Name
SANTA ROSA HEALTHCARE
Subdivision Name
CHRISTUS SANTA ROSA HOSPITAL MEDICAL CENTER
Type
Disproportionate Share Hospital
340B ID
DSH450237
Entity Address
2827 BABCOCK ROAD
SAN ANTONIO, TX 78229
Medicare Provider Number
450237
Participating Start Date
7/1/2023
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
Walmart Pharmacy 10-7611
Pharmacy Address
2501 Perry Rd
Plainfield, IN 46168
Pharmacy Comments
Contract Details
Approval Date
10/16/2023
Contract Begin Date
1/1/2024
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/17/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Steve Chen, CFO
(210) 321-8031
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
10/16/2023
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