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FIRST PHARMACY CHILDRENS MEDICAL CTR OF
PED453316-05 Children’s Medical Center Plano
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Covered Entity Details
Entity Name
Children’s Medical Center Plano
Subdivision Name
Children's Health Specialty Center Plano Campus / Physical Medicine & Rehab
Type
Children's Hospital
340B ID
PED453316-05
Entity Address
7609 Preston Road
P3600
Plano, TX 75024-3214
Medicare Provider Number
453316
Outpatient Facility Provider Number
Participating Start Date
4/1/2017
Last Recertification Date
9/2/2020
Entity Termination Date
4/1/2021
Pharmacy Details
Pharmacy Name
FIRST PHARMACY CHILDRENS MEDICAL CTR OF
Pharmacy Address
CHILDREN'S HEALTH SYSTEM OF TEXAS
1935 MEDICAL DISTRICT DR STE E1000
DALLAS, TX 75235
Pharmacy Comments
Contract Details
Approval Date
1/2/2019
Contract Begin Date
4/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
4/1/2021
Covered Entity Terminated
Contacts
Covered Entity Signing Official
David T Berry, CHST President, System Clinical Operations
(214) 456-2143
Contract Pharmacy Representative
Children's Medical Center Dallas
David LaVecchia, Retail Pharmacy Manager
(214) 456-3212
Signed By Date
1/2/2019
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