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WAL-MART PHARMACY 10-1186
CAH451375-00 Liberty Dayton Regional Medical Center
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Covered Entity Details
Entity Name
Liberty Dayton Regional Medical Center
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH451375-00
Entity Address
1353 N.Travis St.
Liberty, TX 77575
Medicare Provider Number
451375
Participating Start Date
7/1/2012
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-1186
Pharmacy Address
2121 US BYPASS 146
LIBERTY, TX 77575
Pharmacy Comments
Contract Details
Approval Date
11/20/2012
Contract Begin Date
1/1/2013
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Jim Koulovatos, CEO
(936) 336-7316 Ext: 149
Contract Pharmacy Representative
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
10/8/2012
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