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WAL-MART PHARMACY 10-5863
DSH370037 SSM ST ANTHONY HOSPITAL
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Covered Entity Details
Entity Name
SSM ST ANTHONY HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH370037
Entity Address
1000 N Lee Ave
OKLAHOMA CITY, OK 73102
Medicare Provider Number
370037
Participating Start Date
10/1/2006
Last Recertification Date
8/31/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-5863
Pharmacy Address
7520 E RENO AVE
MIDWEST CITY, OK 73110
Pharmacy Comments
Contract Details
Approval Date
4/13/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Shasta Manuel, VP of Finance CFO
(405) 272-7282
Contract Pharmacy Representative
WALMART
Julie Howard, Manager Contracting & Channel Management
(479) 277-1498
Signed By Date
4/13/2018
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