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WAL-MART PHARMACY 10-0901
DSH450104 GUADALUPE REGIONAL MEDICAL CENTER
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Covered Entity Details
Entity Name
GUADALUPE REGIONAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450104
Entity Address
1215 E. COURT
SEGUIN, TX 78155
Medicare Provider Number
450104
Participating Start Date
10/1/2004
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0901
Pharmacy Address
550 S. 123 BYPASS
SEGUIN, TX 78155
Pharmacy Comments
Contract Details
Approval Date
6/22/2012
Contract Begin Date
6/22/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/28/2016
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
PENNY WALLACE, CFO
(830) 379-2411
Contract Pharmacy Representative
Wal--Mart
Marcus Osborne, Sales & Contracting
(479) 204-8452
Signed By Date
6/15/2012
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