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WAL-MART PHARMACY 10-0404
DSH450272 CHRISTUS Santa Rosa Hospital - San Marcos
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Covered Entity Details
Entity Name
CHRISTUS Santa Rosa Hospital - San Marcos
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450272
Entity Address
1301 Wonder World Drive
San Marcos, TX 78666
Medicare Provider Number
450272
Participating Start Date
10/1/2004
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0404
Pharmacy Address
1015 HIGHWAY 80
SAN MARCOS, TX 78666
Pharmacy Comments
Contract Details
Approval Date
10/6/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/6/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Jesse Sutton, CFO
(512) 753-3505
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
10/6/2014
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