Contract Pharmacy Details

WAL-MART PHARMACY 10-5174
FQHCLA336 BAYOUCLINIC, INC.

Covered Entity Details

Entity Name

BAYOUCLINIC, INC.

Subdivision Name

BayouClinic, Inc.

Type

Health Center Program Look-Alike

340B ID

FQHCLA336

Entity Address

13833 Tapia Lane
Bayou La Batre, AL 36509-2515

Grant Number

LALCS00109

Participating Start Date

1/1/2016

Last Recertification Date

2/9/2018

Entity Termination Date

1/1/2019

Pharmacy Details

Pharmacy Name

WAL-MART PHARMACY 10-5174

Pharmacy Address

7855 MOFFETT RD
SEMMES, AL 36575

Pharmacy Comments

Contract Details

Approval Date

10/17/2016

Contract Begin Date

1/1/2017

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

1/1/2019
Covered Entity Terminated

Contacts

Covered Entity Signing Official

Julie Taylor, Executive Director
(251) 824-4985

Contract Pharmacy Representative

Walmart
Julie Howard, 340B Program Manager
(479) 277-1498

Signed By Date

10/17/2016

340B Drug Pricing Program Database