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WAL-MART PHARMACY 10-0260
DSH450051 METHODIST DALLAS MEDICAL CENTER
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Covered Entity Details
Entity Name
METHODIST DALLAS MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450051
Entity Address
1441 NORTH BECKLEY AVENUE
DALLAS, TX 75203
Medicare Provider Number
450051
Participating Start Date
7/1/2005
Last Recertification Date
9/6/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0260
Pharmacy Address
1200 N. HIGHWAY 77
WAXAHACHIE, TX 75165
Pharmacy Comments
Contract Details
Approval Date
4/12/2018
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
Martin L. Koonsman, President
(214) 947-2523
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
4/12/2018
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