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WAL-MART PHARMACY 10-1405
CAH451332-00 PALACIOS COMMUNITY MEDICAL CENTER
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Covered Entity Details
Entity Name
PALACIOS COMMUNITY MEDICAL CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH451332-00
Entity Address
311 GREEN AVE
PALACIOS, TX 77465-3213
Medicare Provider Number
451332
Participating Start Date
9/30/2010
Last Recertification Date
9/10/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1405
Pharmacy Address
4600 7TH STREET
BAY CITY, TX 77414
Pharmacy Comments
Contract Details
Approval Date
12/3/2012
Contract Begin Date
1/1/2013
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
DON BATES, CEO
(361) 972-2511 Ext: 4142
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
10/10/2012
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