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WAL-MART PHARMACY 10-1073
CAH451323-00 AdventHealth Rollins Brook
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Covered Entity Details
Entity Name
AdventHealth Rollins Brook
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH451323-00
Entity Address
608 North Key Avenue
LAMPASAS, TX 76550
Medicare Provider Number
451323
Participating Start Date
1/1/2011
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1073
Pharmacy Address
1710 CENTRAL TEXAS EXPRESSWAY
LAMPASAS, TX 76550
Pharmacy Comments
Contract Details
Approval Date
2/20/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/8/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Carlyle Walton, CEO
(254) 519-8165
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/10/2013
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