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WAL-MART PHARMACY 10-0456
CH06084C SU CLINICA FAMILIAR
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Covered Entity Details
Entity Name
SU CLINICA FAMILIAR
Subdivision Name
Southern Cameron County Clinic
Type
HRSA-Funded Health Center
340B ID
CH06084C
Entity Address
105 E. Alton Gloor Blvd.
BROWNSVILLE, TX 78526
Grant Number
H80CS00348
Participating Start Date
7/1/1993
Last Recertification Date
2/21/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0456
Pharmacy Address
3500 WEST ALTON GLOOR BLVD.
BROWNSVILLE, TX 78520
Pharmacy Comments
Contract Details
Approval Date
7/15/2015
Contract Begin Date
10/1/2015
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
ELENA MARIN, CEO
(956) 365-6010 Ext: 1330
Contract Pharmacy Representative
Wal-Mart
Marcus Osbourne, Vice President
(800) 939-2022
Signed By Date
7/15/2015
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