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WAL-MART PHARMACY 10-4279
DSH450723 METHODIST CHARLTON MEDICAL CENTER
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Covered Entity Details
Entity Name
METHODIST CHARLTON MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450723
Entity Address
3500 WEST WHEATLAND ROAD
DALLAS, TX 75237-3460
Medicare Provider Number
450723
Participating Start Date
7/1/2005
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-4279
Pharmacy Address
400 NORTH HIGHWAY 67
MIDLOTHIAN, TX 76065
Pharmacy Comments
Contract Details
Approval Date
4/11/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/12/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
FRANCES LAUKAITIS, PRESIDENT
(214) 947-7707
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/11/2018
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