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Walmart Pharmacy 10-7611
RRC450023-00 CITIZENS MEDICAL CENTER
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Covered Entity Details
Entity Name
CITIZENS MEDICAL CENTER
Subdivision Name
Type
Rural Referral Center
340B ID
RRC450023-00
Entity Address
2701 HOSPITAL DRIVE
VICTORIA, TX 77901
Medicare Provider Number
450023
Participating Start Date
7/1/2023
Last Recertification Date
9/9/2024
Pharmacy Details
Pharmacy Name
Walmart Pharmacy 10-7611
Pharmacy Address
2501 Perry Rd
Plainfield, IN 46168
Pharmacy Comments
Contract Details
Approval Date
4/10/2024
Contract Begin Date
7/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Duane L. Woods, CFO
(361) 572-5009
Contract Pharmacy Representative
Walmart
Van Donn, Director of Contracting
(479) 277-3719
Signed By Date
4/10/2024
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