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WAL-MART PHARMACY 10-0443
CAH451330-00 MEDINA COUNTY HOSPITAL DISTRICT
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Covered Entity Details
Entity Name
MEDINA COUNTY HOSPITAL DISTRICT
Subdivision Name
MEDINA REGIONAL HOSPITAL
Type
Critical Access Hospital
340B ID
CAH451330-00
Entity Address
3100 AVENUE E
HONDO, TX 78861
Medicare Provider Number
451330
Participating Start Date
9/2/2010
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0443
Pharmacy Address
109 22ND STREET
HONDO, TX 78861
Pharmacy Comments
Contract Details
Approval Date
4/10/2012
Contract Begin Date
4/10/2012
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Brian Petter, COO
(830) 426-7884
Contract Pharmacy Representative
Wal--Mart
Marcus Osborne, Sales & Contracting
(479) 204-8452
Signed By Date
3/30/2012
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