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WAL-MART PHARMACY 10-1042
CH061949AX Lone Star Circle Of Care
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Covered Entity Details
Entity Name
Lone Star Circle Of Care
Subdivision Name
Lone Star Circle of Care Pediatrics at MoPac North
Type
HRSA-Funded Health Center
340B ID
CH061949AX
Entity Address
12201 Renfert Way STE 105
Austin, TX 78758-5362
Grant Number
H80CS04289
Participating Start Date
4/7/2022
Last Recertification Date
2/12/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1042
Pharmacy Address
488 HIGHWAY 71 WEST
BASTROP, TX 78602
Pharmacy Comments
Contract Details
Approval Date
7/12/2024
Contract Begin Date
10/1/2024
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jon Calvin, CEO
(512) 686-0523 Ext: 10451
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
7/12/2024
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