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WAL-MART PHARMACY 10-0812
DSH450221 MOORE COUNTY HOSPITAL DISTRICT DBA MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
MOORE COUNTY HOSPITAL DISTRICT DBA MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450221
Entity Address
224 EAST 2ND STREET
DUMAS, TX 79029
Medicare Provider Number
450221
Participating Start Date
7/1/2009
Last Recertification Date
11/29/2017
Entity Termination Date
4/1/2018
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0812
Pharmacy Address
2003 S. DUMAS AVE
DUMAS, TX 79029
Pharmacy Comments
Contract Details
Approval Date
1/4/2016
Contract Begin Date
4/1/2016
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
JEFF Ray TURNER, CEO
(806) 935-7171
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
1/4/2016
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