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WAL-MART PHARMACY 10-0165
DSH450475 East Texas Medical Center Henderson
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Covered Entity Details
Entity Name
East Texas Medical Center Henderson
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450475
Entity Address
300 WILSON STREET
HENDERSON, TX 75652
Medicare Provider Number
450475
Participating Start Date
1/1/2008
Last Recertification Date
11/9/2017
Entity Termination Date
4/1/2018
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0165
Pharmacy Address
2121 HWY. 79 SOUTH
HENDERSON, TX 75654
Pharmacy Comments
Contract Details
Approval Date
3/8/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
MARK LEITNER, CEO
(903) 655-3616
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/15/2013
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