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HEB PHARMACY #182
DSH450054 SCOTT AND WHITE MEMORIAL HOSPITAL
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Covered Entity Details
Entity Name
SCOTT AND WHITE MEMORIAL HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450054
Entity Address
2401 S 31ST ST
TEMPLE, TX 76508
Medicare Provider Number
450054
Participating Start Date
4/1/2006
Last Recertification Date
8/29/2024
Pharmacy Details
Pharmacy Name
HEB PHARMACY #182
Pharmacy Address
3002 S. 31ST STREET
TEMPLE, TX 76502
Pharmacy Comments
Contract Details
Approval Date
10/10/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
Shahin Motakef, CEO
(254) 724-6583
Contract Pharmacy Representative
HEB Pharmacy
Jay Beuche, Manager Contracting
(210) 938-8578
Signed By Date
10/10/2018
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