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RANDALLS FOOD AND DRUGS LP
DSH450723 METHODIST CHARLTON MEDICAL CENTER
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Covered Entity Details
Entity Name
METHODIST CHARLTON MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450723
Entity Address
3500 WEST WHEATLAND ROAD
DALLAS, TX 75237-3460
Medicare Provider Number
450723
Participating Start Date
7/1/2005
Last Recertification Date
9/4/2024
Pharmacy Details
Pharmacy Name
RANDALLS FOOD AND DRUGS LP
Pharmacy Address
TOM THUMB PHARMACY #1786
4215 SOUTH CARRIER
GRAND PRAIRIE, TX 75052
Pharmacy Comments
Contract Details
Approval Date
7/17/2018
Contract Begin Date
10/1/2018
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
10/28/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
FRANCES LAUKAITIS, PRESIDENT
(214) 947-7707
Contract Pharmacy Representative
Albertsons Companies
Chuck Hanson, Senior 340B Program Manager
(208) 395-6304
Signed By Date
7/17/2018
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