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MAXOR SPECIALTY PHARMACY
PED453302-00 CHILDREN'S MEDICAL CENTER DALLAS
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Covered Entity Details
Entity Name
CHILDREN'S MEDICAL CENTER DALLAS
Subdivision Name
Type
Children's Hospital
340B ID
PED453302-00
Entity Address
1935 MEDICAL DISTRICT DRIVE
DALLAS, TX 75235
Medicare Provider Number
453302
Participating Start Date
4/1/2010
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
MAXOR SPECIALTY PHARMACY
Pharmacy Address
102 SW 3RD AVE
AMARILLO, TX 79101-1443
Pharmacy Comments
Contract Details
Approval Date
7/6/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
David T Berry, CHST President, System Clinical Operations
(214) 456-2143
Contract Pharmacy Representative
Maxor
Nick Pacello, Vice President of Health Systems
(704) 258-5175
Signed By Date
7/6/2018
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