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WAL-MART PHARMACY 10-0781
SCH450219-00 Baylor Scott & White Medical Center - Llano
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Covered Entity Details
Entity Name
Baylor Scott & White Medical Center - Llano
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH450219-00
Entity Address
200 W. Ollie St.
Llano, TX 78643
Medicare Provider Number
450219
Participating Start Date
10/1/2013
Last Recertification Date
9/6/2016
Entity Termination Date
4/1/2017
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0781
Pharmacy Address
2700 US HWY 281 NORTH
MARBLE FALLS, TX 78654
Pharmacy Comments
Contract Details
Approval Date
9/11/2013
Contract Begin Date
10/1/2013
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2017
Contacts
Covered Entity Signing Official
Kevin A. Leeper, CEO
(325) 247-7868
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
9/11/2013
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