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WAL-MART PHARMACY 10-0251
CAH451380-00 East Texas Medical Center Quitman
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Covered Entity Details
Entity Name
East Texas Medical Center Quitman
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH451380-00
Entity Address
117 N. Winnsboro Street
Quitman, TX 75783
Medicare Provider Number
451380
Participating Start Date
4/1/2013
Last Recertification Date
11/7/2017
Entity Termination Date
4/1/2018
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0251
Pharmacy Address
135 N.E. LOOP 564
MINEOLA, TX 75773
Pharmacy Comments
Contract Details
Approval Date
10/9/2014
Contract Begin Date
1/1/2015
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Warren J. Robicheaux, Sr. Administrator
(903) 946-5501
Contract Pharmacy Representative
Healdsburg District Hospital
Kathi Phelps, Manager Contracting
(479) 277-3719
Signed By Date
10/9/2014
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