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WAL-MART PHARMACY 10-5315
DSH100025 SACRED HEART HEALTH SYSTEM
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Covered Entity Details
Entity Name
SACRED HEART HEALTH SYSTEM
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH100025
Entity Address
5151 NORTH 9TH AVENUE
PENSACOLA, FL 32504
Medicare Provider Number
100025
Participating Start Date
7/1/2003
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5315
Pharmacy Address
2354 COMMERCE PARK DR.
ORLANDO, FL 32819
Pharmacy Comments
Contract Details
Approval Date
7/11/2017
Contract Begin Date
10/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
9/26/2019
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Henry Stovall, President
(850) 416-7681
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
7/11/2017
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