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WAL-MART PHARMACY 10-0353
SCH450085-00 Graham Regional Medical Center
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Covered Entity Details
Entity Name
Graham Regional Medical Center
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH450085-00
Entity Address
1301 Montgomery Road
Graham, TX 76450
Medicare Provider Number
450085
Participating Start Date
1/1/2014
Last Recertification Date
9/7/2016
Entity Termination Date
1/1/2017
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0353
Pharmacy Address
2121 HWY 16 SOUTH
GRAHAM, TX 76450
Pharmacy Comments
Contract Details
Approval Date
12/31/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/1/2017
Contacts
Covered Entity Signing Official
Bonnie Blevins, CFO
(940) 521-5411
Contract Pharmacy Representative
Wal-Mart
Marcus Osborne, V.P. Health & Wellness, Sales & Contracting
(479) 204-9374
Signed By Date
12/31/2013
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