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WAL-MART PHARMACY 10-1618
DSH150002 THE METHODIST HOSPITALS
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Covered Entity Details
Entity Name
THE METHODIST HOSPITALS
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH150002
Entity Address
600 GRANT ST
GARY, IN 46402
Medicare Provider Number
150002
Participating Start Date
4/1/2003
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1618
Pharmacy Address
2936 E. 79TH AVE
MERRILLVILLE, IN 46410
Pharmacy Comments
Contract Details
Approval Date
4/10/2015
Contract Begin Date
7/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Matthew Shawn Doyle, President & CEO
(219) 886-4608
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
4/10/2015
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