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WAL-MART PHARMACY 10-0163
DSH450508 LION STAR NACOGDOCHES MEMORIAL HOSP
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Covered Entity Details
Entity Name
LION STAR NACOGDOCHES MEMORIAL HOSP
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450508
Entity Address
1204 NORTH MOUND STREET
NACOGDOCHES, TX 75961
Medicare Provider Number
450508
Participating Start Date
7/1/2024
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
WAL-MART PHARMACY 10-0163
Pharmacy Address
4810 NORTH ST
NACOGDOCHES, TX 75965
Pharmacy Comments
Contract Details
Approval Date
4/18/2018
Contract Begin Date
7/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
gary Kendrick, Interim CEO
(936) 568-8520
Contract Pharmacy Representative
Walmart
Julie Howard, Senior Manager, 340B Program
(479) 277-1498
Signed By Date
4/18/2018
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