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WAL-MART PHARMACY 10-0523
DSH450037 GOOD SHEPHERD MEDICAL CENTER
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Covered Entity Details
Entity Name
GOOD SHEPHERD MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450037
Entity Address
700 E. MARSHALL AVENUE
LONGVIEW, TX 75601
Medicare Provider Number
450037
Participating Start Date
7/1/2010
Last Recertification Date
8/29/2018
Entity Termination Date
7/1/2019
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0523
Pharmacy Address
4609 NW LOOP 436
CARTHAGE, TX 75633
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
7/1/2019
Covered Entity Terminated
Contacts
Covered Entity Signing Official
RON SHORT, EXECUTIVE VICE PRESIDENT/CAO
(903) 315-1121
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
1/4/2016
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