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WAL-MART PHARMACY 10-5246
DSH450848 Memorial Hermann Sugar Land Hospital
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Covered Entity Details
Entity Name
Memorial Hermann Sugar Land Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450848
Entity Address
17500 West Grand Parkway
Sugar Land, TX 77479
Medicare Provider Number
450848
Participating Start Date
1/1/2012
Last Recertification Date
9/5/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5246
Pharmacy Address
1255 HWY 59 LOOP
WHARTON, TX 77488
Pharmacy Comments
Contract Details
Approval Date
10/24/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/14/2017
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Daisy Yeung, CFO
(281) 725-5217
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
10/24/2014
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