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WAL-MART PHARMACY 10-0364
SCH450210-00 East Texas Medical Center Carthage
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Covered Entity Details
Entity Name
East Texas Medical Center Carthage
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH450210-00
Entity Address
409 West Cottage Road
Carthage, TX 75633
Medicare Provider Number
450210
Participating Start Date
7/1/2013
Last Recertification Date
11/8/2017
Entity Termination Date
4/1/2018
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0364
Pharmacy Address
765 HURST ST
CENTER, TX 75935-3415
Pharmacy Comments
Contract Details
Approval Date
8/6/2013
Contract Begin Date
7/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Gary Hudson, Administrator
(903) 694-4652
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
8/6/2013
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