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WAL-MART PHARMACY 10-0524
CAH451364-00 OTTO KAISER MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
OTTO KAISER MEMORIAL HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH451364-00
Entity Address
3349 S Hwy 181
KENEDY, TX 78119
Medicare Provider Number
451364
Participating Start Date
1/1/2024
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0524
Pharmacy Address
200 BUSINESS PARK DR
KENEDY, TX 78119
Pharmacy Comments
Contract Details
Approval Date
4/10/2012
Contract Begin Date
4/10/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2016
Contacts
Covered Entity Signing Official
Nathan Tudor, CEO
(830) 583-3401
Contract Pharmacy Representative
Wal--Mart
Marcus Osborne, Sales & Contracting
(479) 204-8452
Signed By Date
3/30/2012
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