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WALGREEN CO.
DSH450565 Palo Pinto General Hospital
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Covered Entity Details
Entity Name
Palo Pinto General Hospital
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450565
Entity Address
400 SW 25th Avenue
Mineral Wells, TX 76067-8246
Medicare Provider Number
450565
Participating Start Date
10/1/2011
Last Recertification Date
9/13/2024
Pharmacy Details
Pharmacy Name
WALGREEN CO.
Pharmacy Address
DBA: WALGREENS # 10258
201 FM 1821
MINERAL WELLS, TX 76067
Pharmacy Comments
Contract Details
Approval Date
10/9/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Daniel W Smith, Interim CEO
(940) 328-6401
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/9/2018
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