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WAL-MART PHARMACY 10-0804
DSH450565 Palo Pinto General Hospital
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Covered Entity Details
Entity Name
Palo Pinto General Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450565
Entity Address
400 SW 25th Avenue
Mineral Wells, TX 76067-8246
Medicare Provider Number
450565
Participating Start Date
10/1/2011
Last Recertification Date
9/13/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0804
Pharmacy Address
601 NO. FM 1821
MINERAL WELLS, TX 76067
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
Harris Brooks, CEO
(328) 940-6403
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
10/11/2012
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