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CVS PHARMACY, INC.
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
CVS PHARMACY, INC.
Pharmacy Address
DBA: CVS/PHARMACY # 06781
2323 W ILLINOIS AVE
DALLAS, TX 75224
Pharmacy Comments
Contract Details
Approval Date
7/9/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Martin L. Koonsman, President
(214) 947-2523
Contract Pharmacy Representative
CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782
Signed By Date
7/9/2018
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