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WAL-MART PHARMACY 10-0288
DSH450573 CHRISTUS JASPER MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
CHRISTUS JASPER MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450573
Entity Address
1275 MARVIN HANCOCK DRIVE
JASPER, TX 75951
Medicare Provider Number
450573
Participating Start Date
10/1/2004
Last Recertification Date
8/15/2024
Entity Termination Date
1/1/2025
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0288
Pharmacy Address
115 COBB MILL RD
WOODVILLE, TX 75979
Pharmacy Comments
Contract Details
Approval Date
3/5/2012
Contract Begin Date
3/5/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/19/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Libby Lewis, CFO
(409) 984-1867
Contract Pharmacy Representative
Wal--Mart
Marcus Osborne, Sales & Contracting
(479) 204-8452
Signed By Date
2/24/2012
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