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Walmart Pharmacy 10-7611
DSH450565 Palo Pinto General Hospital
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Covered Entity Details
Entity Name
Palo Pinto General Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450565
Entity Address
400 SW 25th Avenue
Mineral Wells, TX 76067-8246
Medicare Provider Number
450565
Participating Start Date
10/1/2011
Last Recertification Date
9/13/2024
Pharmacy Details
Pharmacy Name
Walmart Pharmacy 10-7611
Pharmacy Address
2501 Perry Rd
Plainfield, IN 46168
Pharmacy Comments
Contract Details
Approval Date
1/9/2024
Contract Begin Date
4/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Ross Korkmas, CEO
(940) 325-7891 Ext: 6400
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
1/9/2024
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