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WAL-MART PHARMACY 10-0567
CAH451305-00 CHI St. Joseph Health - Burleson Hospital
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Covered Entity Details
Entity Name
CHI St. Joseph Health - Burleson Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH451305-00
Entity Address
1101 Woodson Dr
Caldwell, TX 77836
Medicare Provider Number
451305
Participating Start Date
1/1/2013
Last Recertification Date
8/26/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0567
Pharmacy Address
475 STATE HIGHWAY 36 NORTH
CALDWELL, TX 77836
Pharmacy Comments
Contract Details
Approval Date
2/28/2013
Contract Begin Date
4/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
8/11/2015
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Ricardo Diaz, Chief Operating Officer
(979) 776-2580
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
1/15/2013
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