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WALMART PHARMACY 10-5632
DSH050093 SAINT AGNES MEDICAL CENTER
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Covered Entity Details
Entity Name
SAINT AGNES MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH050093
Entity Address
1303 E HERNDON AVE
FRESNO, CA 93720
Medicare Provider Number
050093
Participating Start Date
1/1/2014
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-5632
Pharmacy Address
1804 EAST ASHLAN AVE.
FRESNO, CA 93726
Pharmacy Comments
Contract Details
Approval Date
10/14/2015
Contract Begin Date
1/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
NANCY HOLLINGSWORTH, CEO
(559) 450-3301
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
10/14/2015
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