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WAL-MART PHARMACY 10-0901
DSH450235 GONZALES HEALTHCARE SYSTEMS
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Covered Entity Details
Entity Name
GONZALES HEALTHCARE SYSTEMS
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450235
Entity Address
1110 N SARAH DEWITT DRIVE
GONZALES, TX 78629
Medicare Provider Number
450235
Participating Start Date
10/1/2004
Last Recertification Date
9/2/2019
Entity Termination Date
5/6/2020
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0901
Pharmacy Address
550 S. 123 BYPASS
SEGUIN, TX 78155
Pharmacy Comments
Contract Details
Approval Date
7/18/2014
Contract Begin Date
10/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/6/2020
Covered Entity Terminated
Contacts
Covered Entity Signing Official
CHUCK NORRIS, ADMINISTRATOR
(830) 672-7581 Ext: 1001
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
7/18/2014
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