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WAL-MART PHARMACY 10-0592
DSH170122 Ascension Via Christi Hospitals Wichita, Inc
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Covered Entity Details
Entity Name
Ascension Via Christi Hospitals Wichita, Inc
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH170122
Entity Address
929 N. St. Francis
Wichita, KS 67214
Medicare Provider Number
170122
Participating Start Date
1/1/2012
Last Recertification Date
8/15/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0592
Pharmacy Address
2020 NORTH NELSON DRIVE
DERBY, KS 67037
Pharmacy Comments
Contract Details
Approval Date
11/14/2012
Contract Begin Date
11/14/2012
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
5/16/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Michael A. Wegner, Senior VP of Finance & CFO
(316) 268-8525
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
9/27/2012
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