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MAXOR SPECIALTY PHARMACY
DSH450056 Ascension Seton d/b/a Ascension Seton Medical Center Austin
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Covered Entity Details
Entity Name
Ascension Seton d/b/a Ascension Seton Medical Center Austin
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450056
Entity Address
1201 WEST 38TH STREET
AUSTIN, TX 78705
Medicare Provider Number
450056
Participating Start Date
4/1/2017
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
MAXOR SPECIALTY PHARMACY
Pharmacy Address
6101 43RD ST, STE C
LUBBOCK, TX 79407
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
11/13/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Tad Allen Hatton, VP/COO
(512) 484-3507
Contract Pharmacy Representative
Maxor National Pharmacy Services, LLC
Ross Halsne, VP, Market Strategy
(612) 210-8655
Signed By Date
7/17/2018
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